Sympathectomy in refractory ventricular arrhythmias in patients with left ventricular assist device: a grand round case report

Ventricular tachycardias (VTs) are a life-threatening complication of patients with end-stage left ventricular dysfunction, and are a frequent cause for considering advanced therapies. Their management in patients supported by a left ventricular assist device (LVAD) presents unique challenges, requiring a multidisciplinary approach to tailored strategies.

We present the case of a 70-year-old male with a history of VTs who underwent HeartMate 3 (Abbott, USA) implantation for advanced heart failure secondary to ischaemic cardiomyopathy and refractory VTs. Following LVAD implantation, he developed an electrical storm refractory to a combination of antiarrhythmic drugs and both radiofrequency and pulse-field catheter ablations. Due to persistent VT, neuromodulation of the sympathetic nervous system was considered as a last-resort strategy. Percutaneous radiofrequency ablation of the stellate ganglion was unsuccessful; however, left surgical sympathectomy effectively controlled the arrhythmias. The patient has remained free of arrhythmic events at 1-year follow-up.

Management of VTs in LVAD carriers is typically stepwise, beginning with correction of reversible triggers and the use of antiarrhythmic drugs. However, monotherapy is often insufficient, and achieving arrhythmic control often depends on a multimodal approach. In cases refractory to conventional measures, escalation to catheter ablation, neuromodulation techniques, and stereotactic arrhythmia radioablation may prove effective.