The role of advanced echocardiographic parameters in the management of patients with cardiomyopathy undergoing cardiac sympathetic denervation
P Meynet, C Picollo, E Baldi, S Savastano, M Anselmino, A Greco, M Imazio, L Leoni, M Grimaldi, F Angelini, C Raineri, R Rordorf, A Vairo, G M De Ferrari, V DusiAbstract
Introduction and Objectives
Cardiac sympathetic denervation (CSD) is an emerging therapy for recurrent ventricular tachycardia (VT) refractory to medical therapy and/or catheter ablation. In structural heart disease (SHD), existing data suggest greater efficacy of bilateral CSD (BCSD) compared with left-sided CSD (LCSD); however, evidence regarding the impact of BCSD on cardiac mechanics remains limited. The primary objective of this study was to assess the acute and mid- to long-term echocardiographic effects of CSD in patients with advanced SHD. Secondary objectives included evaluation of clinical outcomes and the antiarrhythmic efficacy of the procedure.
Materials and Methods
This prospective, observational, two-center study included patients with SHD who underwent minimally invasive thoracoscopic CSD for antiarrhythmic purposes between April 2016 and December 2024. Patients underwent standard and, when feasible, advanced transthoracic echocardiography assessments at predefined time points: 24–48 hours prior to CSD, 3–7 days post-CSD (up to 15 days if acoustic window were suboptimal), and every 6 months during follow-up. Advanced parameters included left and right ventricular global longitudinal strain (GLS), electromechanical window (EMW), and mechanical dispersion (MD).
Results
Fifty patients were included (age 56 ± 16 years, 86% male), 86% with non-ischemic cardiomyopathy (63% dilated, 23% non-dilated, 12% hypertrophic, 2% arrhythmogenic). 90% underwent BCSD. Mean left ventricular ejection fraction (LVEF) was 33 ± 12%. 98% had an implantable cardioverter-defibrillator. 32% were in NYHA class ≥ III, and 28% were listed for heart transplantation/LVAD. At follow-up (median 16 months; IQR 4–38), 13 patients (26%) died, 6 (12%) underwent transplantation, and 3 (6%) received an LVAD. Post-procedural echocardiography demonstrated no adverse effects on biventricular contractility, with findings confirmed at 6 (n = 25 BCSD) and 12 months (n = 18 BCSD). LVEF improved at 6 months (38 ± 11%, p = 0.011), returning to baseline at 12 months. MD showed a mild reduction after CSD (98 ± 52 ms vs. 95 ± 55 ms, p = 0.03), not sustained at follow-up. EMW remained unchanged. No correlations were identified among LVEF, EMW, and MD. During follow-up, 50% of patients experienced recurrent shocks, 62% received device therapies, and 40% developed VT storm, with an overall significant reduction in arrhythmic burden. NYHA class ≥III and LCSD were predictors of arrhythmic recurrences. Predictors of VT storm recurrences included NYHA class ≥III and pre-CSD VT cycle length < 200 bpm. In patients with advanced echocardiographic data (n=37), pre-CSD MD < 90 ms independently predicted arrhythmic recurrences.
Conclusions
BCSD is safe and effective for ventricular arrhythmic burden reduction, even in patients with advanced SHD. Incorporating MD and EMW into routine echocardiographic evaluation may help identify higher-risk patients and improve selection of CSD candidates.