Neuromodulation for the Treatment of Refractory Ventricular Arrhythmias

• Published in: JACC. Clinical electrophysiology 2023-02, Vol.9 (2), p.161-169
• Main Authors: Markman, Timothy M., Gugger, Douglas, Arkles, Jeffrey, Riley, Michael P., Dixit, Sanjay, Guandalini, Gustavo S., Frankel, David S., Epstein, Andrew E., Callans, David J., Singhal, Sunil, Marchlinski, Francis E., Nazarian, Saman
• Format: Article
• Language: English
• Subjects: Aged; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Autonomic Nerve Block; cardiac sympathetic denervation; Heart; Humans; Middle Aged; neuromodulation; Retrospective Studies; stellate ganglion block; transcutaneous magnetic stimulation; ventricular tachycardia
• ISSN: 2405-500X; 2405-5018
• DOI: 10.1016/j.jacep.2022.08.031

Neuromodulation is increasingly recognized as a therapeutic strategy for patients with refractory ventricular arrhythmias (VAs). Percutaneous stellate ganglion blockade (SGB), transcutaneous magnetic stimulation (TcMS), and surgical cardiac sympathetic denervation (CSD) have all been utilized in this setting. This study sought to characterize contemporary use and outcomes of these neuromodulation techniques for patients with refractory VA. This retrospective cohort study included all patients at the Hospital of the University of Pennsylvania with antiarrhythmic drug (AAD)-refractory VA from 2019 to 2021 who were treated with SGB, TcMS, or CSD. A total of 34 patients (age 61 ± 14 years, 15 polymorphic VAs [44%], refractory to 1.8 ± 0.8 AADs) met inclusion criteria. SGB was performed on 11 patients (32%), TcMS on 19 (56%), and CSD on 7 (21%). Neuromodulation was associated with a reduction in the number of episodes of sustained VAs from 7 [IQR: 4-12] episodes in the 24 hours before the initial neuromodulation strategy to 0 [IQR: 0-1] episodes in the subsequent 24 hours (P < 0.001). During 1.2 ± 1.1 years of follow-up, 21 (62%) experienced recurrent VAs, and among those patients, the median time to recurrence was 3 [IQR: 1-25] days. Outcomes were similar among patients with monomorphic and polymorphic VAs. Among patients who had an acute myocardial infarction within 30 days before neuromodulation, the burden of VAs decreased from 11 [IQR: 7-12] episodes to 0 episodes in the 24 hours after treatment. Autonomic neuromodulation with SGB, TcMS, or CSD in patients with AAD-refractory VAs is safe and results in substantial acute reduction of VA although recurrent arrhythmias are common, and not all patients experience a reduction in arrhythmia burden. [Display omitted]