Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation

• Published in: Heart rhythm Vol. 16; no. 1; pp. 117 - 124
• Main Authors: Assis, Fabrizio R., Yu, Diana H., Zhou, Xun, Sidhu, Sunjeet, Bapna, Anisha, Engelman, Zoar J., Misra, Satish, Okada, David R., Chrispin, Jonathan, Berger, Ronald, Mandal, Kaushik, Lee, Hans, Tandri, Harikrishna
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2019
• Subjects: Aortopulmonary window; Cardiac plexus; Denervation; Endobronchial ultrasound; Neuromodulation; Refractory arrhythmia; Stellate ganglia; Sympathectomy; Transtracheal; Ventricular tachycardia; Refractory arrhythmia; Stellate ganglia; Sympathectomy; Transtracheal; Ventricular tachycardia; Endobronchial ultrasound; Aortopulmonary window; Neuromodulation; Cardiac plexus; Denervation
• ISSN: 1547-5271; 1556-3871
• DOI: 10.1016/j.hrthm.2018.07.037

Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dTmax (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery. [Display omitted]