Endoscopic transthoracic sympathicotomy for severe angina

doi:10.1016/S0140-6736(95)90065-9

The Lancet

Volume 345, Issue 8942, 14 January 1995, Pages 97-98

https://doi.org/10.1016/S0140-6736(95)90065-9 Get rights and content

Abstract

We evaluated the antianginal effects of endoscopic transthoracic sympathicotomy (ETS) in 24 patients not eligible for coronary bypass surgery or angioplasty. In this procedure, the sympathetic chain is electrocoagulated under general anaesthesia. No major surgical complications occurred. The frequency of anginal attacks was significantly reduced (p=0·001). The mean increase in maximum exercise capacity was 13 (SD 21) W (p=0·009). ST depression at maximum comparable workload was reduced by 0·052 (0·10) mV (p=0·005). Global ejection fraction during exercise and metaiodobenzylguanidine uptake were unchanged. Heart rate variability analysis showed a reduction of the ratio between low and high frequencies at tilt test (-1·00 [0·96]; p<0·001). We conclude that ETS can be done without major complications, alleviates angina, and increases maximum working capacity in patients with advanced coronary disease.

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Cited by (71)

Minimally-invasive device-based approaches for improving cardiac perfusion
2020, Emerging Technologies for Heart Diseases: Volume 2: Treatments for Myocardial Ischemia and Arrhythmias
Improvements in medical therapy and coronary revascularization have led to an increased survival rate in patients with coronary artery disease (CAD), with a consequent growing number of patients with severe and diffuse CAD which is not amenable to further revascularization procedures. The majority of these patients have either angina pectoris refractory to optimal medical therapy or chronic heart failure symptoms. While the goal of therapy in refractory angina pectoris patients should mostly be directed at improving patients’ symptoms and quality of life, therapy in severe diffuse CAD should be focused on myocardial ischemia reduction and survival improvement. In recent years, a number of innovative non-pharmacological therapeutic options, aimed at improving angina symptoms and quality of life by reducing myocardial ischemia, have been investigated in this challenging patient group. We summarize the different non-pharmacological therapeutic options that are available or are under development, aimed at improving myocardial perfusion in patients with proven myocardial ischemia and CAD not amenable to further revascularization.
Cardiac Autonomic Changes After Thoracic Sympathectomy: A Prospective, Randomized Study
2017, Annals of Thoracic Surgery
Citation Excerpt :
The HR was also significantly decreased in both groups, and the changes were more evident in the sympathectomy group than in the sympathicotomy group. The reduction of HR related to ETS is one of the most replicated findings in the literature [4–9]. Generally, in the resting state (when the stress on cardiovascular system is minimal) HR is mainly under the influence of vagal tone, whereas during exercise increase of HR occurs through a simultaneous decrease in vagal activity and an increase in sympathetic activity.
We evaluated whether cardiac autonomic changes could be associated with different extent of sympathetic nerve resection in the management of essential palmar hyperhidrosis.
Sixty patients with essential palmar hyperhidrosis were randomly allocated to undergo excision of T3 ganglia (sympathicectomy group; n = 30) or to interruption of sympathetic chain at the T2 to T3 level with ganglion sparing (sympathicotomy group; n = 30). Time and frequency domains were measured with a 24-Holter monitor during daytime, nighttime, and 24-hour periods at different interval points (7 days before operation; 24 hours; and 1, 3, and 6 months later), and the differences were statistically compared. Clinical outcomes were also evaluated.
Twenty-eight of 30 patients of the sympathectomy and 29 of 30 patients of the sympathicotomy group completed the study. In both groups, we observed a significant increase (p < 0.05) of vagal activity measurements as root mean square of the successive differences of heart period; proportion of adjacent normal R-R intervals >50 ms; high frequency; and a significant decrease (p < 0.05) of adrenergic activity variables as heart rate, low frequency, and the ratio between low frequency and high frequency during daytime, nighttime, and 24-hour periods. These changes were significantly more evident (p < 0.05) in the sympathectomy group than in the sympathicotomy group. Clinical outcomes were similar between the two groups.
Endoscopic thoracic sympathectomy caused a shift of sympathovagal balance toward parasympathetic tone that seems to be associated with the extent of denervation. This trial was registered at clinicaltrials.gov as NCT02733497.
Facial Blushing: Patient Selection and Long-Term Results
2016, Thoracic Surgery Clinics
Thoracic Sympathectomy for Severe Refractory Multivessel Coronary Artery Spasm
2016, American Journal of Cardiology
Citation Excerpt :
This approach is based on the hypothesis that autonomic tone triggers or predisposes to epicardial CAS.5 The long-term effects of sympathectomy on cardiac autonomic tone have been previously studied,6 and it has been used with good results in patients with severe angina who are not eligible for angioplasty or coronary bypass surgery.7 In the case presented, a VATS sympathectomy was performed with resolution of all symptoms, including postural orthostatic hypotension, and preventing recurrence of angina and arrhythmias at 3- and 6-month follow-up.
Effect of long-term thoracic epidural analgesia on refractory angina pectoris: A 10-year experience
2012, Journal of Cardiothoracic and Vascular Anesthesia
In patients with refractory angina, the adjuvant effects of long-term home self-treatment with thoracic epidural analgesia on angina, quality of life, and safety were evaluated.
A prospective, consecutive study.
A university hospital.
Between January 1998 and August 2007, 152 consecutive patients with refractory angina began treatment with thoracic epidural analgesia by intermittent injections of bupivacaine (139 home treatment and 13 palliative). Data were collected until August 2008; therefore, the follow-up for each patient was between 1 and 9 years.
All but 7 of the patients improved symptomatically, and the improvement was maintained throughout the period of treatment (median = 19 months; range, 1 month-8.9 years). After 1 to 2 weeks, the median (interquartile range [IQR]) Canadian Cardiovascular Society angina class decreased from 4.0 (3.0-4.0) to 2.0 (1.0-2.0), the mean ± standard deviation frequency of anginal attacks decreased from 36 ± 19 to 4.4 ± 6.8 a week, the nitroglycerin intake decreased from 27.7 ± 15.7 to 2.7 ± 4.9 a week, and the median (IQR) overall self-rated quality of life assessed by the visual analog scale increased from 25 (20-30) to 70 (50-75) (all p < 0.001). About one-third of the patients had a dislodgement of the epidural catheter. Apart from 1 epidural hematoma that appeared in 1 patient with a previously undiagnosed bleeding defect, no other serious catheter-related complications occurred.
Long-term self-administered home treatment with thoracic epidural analgesia is a safe, widely available adjuvant treatment for patients with severe refractory angina. It produces symptomatic relief of angina and improves quality of life. The technical development of the method to protect the catheter against dislodgement is needed.
From Heart to Brain: The Genesis and Processing of Cardiac Pain
2012, Canadian Journal of Cardiology
Citation Excerpt :
In the 1980s, there was a renewal of interest, in the form of thoracoscopic excision of the cervical sympathetic ganglia, but because an open thoracotomy was required, with its attendant morbidity and mortality, its attractiveness was limited. In 1995 Wettervik et al.108 evaluated the antianginal effect of ‘endoscopic transthoracic sympathicotomy’ in 24 patients with intractable angina. There were no procedural complications and sympathectomy resulted in a significant reduction in the frequency of anginal attacks with 10 patients (42%) becoming free of angina.
Angina pectoris is important because of its association with heart disease and risk of death. Historically after Heberden's account of angina in 1772, the association of pain with coronary artery disease quickly followed. Within a few years, Burns suggested an etiological role for ischemia. Subsequently, theories of differential myocardial stretch dominated thinking until Lewis' chemical hypothesis in 1932, in which the local release of chemical substances during ischemia was seen as the cause of pain.
This review considers how ischemia at the tissue level triggers activation of afferent nociceptive pain fibres. The afferent projections of sympathetic and vagal afferent fibres are described, with a number of methodologies cited (eg, injection of pseudorabies virus into the heart with mapping of the retrograde viral transport pathways; and elevation of neuronal c-fos synthesis in brain regions activated by capsaicin application to the heart). Our own functional neuroimaging studies of angina are also reviewed.
There are 2 intriguing features of angina. The first is the poor correlation between symptoms and extent of coronary disease. The spectrum ranges from entirely silent myocardial ischemia to that of a functional pain syndrome—the ‘sensitive heart’—of cardiac syndrome X. An even more difficult aspect is the wide variability in symptoms experienced by an individual patient.
A new paradigm is presented which, besides considering myocardial oxygen supply/demand imbalance, also draws insights from the broader field of pain research. Neuromodulation applies at multiple levels of the neuraxis—peripheral nerves, spinal cord, and brain—and it invites exploitation, whether pharmacological or electrical, for the benefit of the cardiac patient in pain.
L'angine de poitrine est importante en raison de son lien avec la maladie cardiaque et le risque de mortalité. Historiquement, après les travaux d'Heberden sur l'angine, en 1772, le lien entre la douleur et la maladie coronarienne a rapidement été reconnu. En quelques années, Burns suggérait un rôle étiologique à l'ischémie. Subséquemment, les théories d'étirement myocardique différentiel ont dominé jusqu'à l'hypothèse chimique de Lewis, en 1932, selon laquelle la libération locale de substances chimiques durant l'ischémie était considérée comme la raison de la douleur.
Cette revue examine comment l'ischémie au niveau tissulaire déclenche l'activation des fibres nociceptives afférentes. Les projections afférentes de fibres afférentes sympathiques et vagales sont décrites, avec un grand nombre de méthodologies citées (par exemple, l'injection du virus de la pseudorage dans le cœur avec cartographie des voies de transport viral rétrograde et l'augmentation de la synthèse neuronale de la protéine c-fos dans les régions du cerveau activées par l'application de capsaïcine au cœur). Nos propres études en imagerie neurologique fonctionnelle sur l'angine sont aussi revues.
Il y a 2 caractéristiques intrigantes de l'angine. La première est la mauvaise corrélation entre les symptômes et l'étendue de la maladie coronarienne. Le spectre s'étend de l'ischémie myocardique silencieuse à celui d'un syndrome de douleur fonctionnelle – le « cœur sensible » – du syndrome X cardiaque. Un aspect encore plus difficile est la grande variabilité dans les symptômes ressentis par chacun des patients. Un nouveau paradigme est présenté lequel, en plus de considérer le déséquilibre entre la demande et l'approvisionnement du myocarde en oxygène, nous donne aussi un aperçu du vaste domaine de la recherche sur la douleur. La neuromodulation applique à plusieurs niveaux de l'axe neural – nerfs périphériques, moelle épinière et cerveau – et elle invite à l'exploitation, tant pharmacologique qu'électrique, au bénéfice du patient cardiaque souffrant de douleur.

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The Lancet

Endoscopic transthoracic sympathicotomy for severe angina

Abstract

Mechanism and significance of cardiac ischemic pain

Prog Cardiovasc Dis

Angina pectoris, a clinical study with special reference to neurosurgical treatment. Thesis

Acta Med Scand

Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease

Anesth Analg

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis

Br J Surg

A review of endoscopic procedures on the upper thoracic sympathetic chain

Archives Surg

Minimally-invasive device-based approaches for improving cardiac perfusion

Cardiac Autonomic Changes After Thoracic Sympathectomy: A Prospective, Randomized Study

Facial Blushing: Patient Selection and Long-Term Results

Thoracic Sympathectomy for Severe Refractory Multivessel Coronary Artery Spasm

Effect of long-term thoracic epidural analgesia on refractory angina pectoris: A 10-year experience

From Heart to Brain: The Genesis and Processing of Cardiac Pain