Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy

Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy in a patient with essential palmar hyperhidrosis: A case report.  
Park SJ, Jee DL.

Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea. djee@medical.yeungnam.ac.kr

Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

Profound Bradycardia in patients having high SDRR:SD sub [partial diffenrential] RR ratios

However, CTS (Chemical Thoracic Sympathectomy) in patients having high SDRR:SD sub [partial diffenrential] RR ratios can result in profound bradycardia.
Anesthesiology. 89(3):666-670, September 1998.
Hirose, Munetaka MD; Imai, Hiroto MD; Ohmori, Misako MD; Matsumoto, Yasunori MD; Amaya, Fumimasa MD; Hosokawa, Toyoshi
MD; Tanaka, Yoshifumi MD

Causes of Syncope:

g) *Syncope via autonomic failure:
i) Neuropathy with autonomic involvement
ii) Antihypertensives, esp. beta-blockers
iii) Surgical sympathectomy
iv) CNS autonomic failure: eg.primary autonomic failure, MSA, spinal cord lesion

Causes of *Collapse and Acute Decreased Conscious State. (* = collapse, as in sudden loss of consciousness). 1. Respiratory (O ...
www.medicine.utas.edu.au/teaching/year6/cam615_616/info/additionaltutes/additionaltutes/med.pdf

Authorised Publication of the School of Medicine
© University of Tasmania ABN 30 764 374 782

baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS

In this study, baroreflex control of HR was completely inhibited in 9 of 21 patients in the depressor test but in only 1 of 19 patients in the pressor test. All patients who showed complete inhibition had received bilateral T2-3 sympathectomy. Responses to decreased blood pressure are mediated by the sympathetic nervous system, whereas responses to increased blood pressure predominantly involve vagal compensation (13). Therefore, it seems that the effects of sympathetic denervation were most prominent in the depressor test after ETS.

The suppression of baroreflex function can be detrimental during anesthetic management. In particular, a poorly preserved baroreflex response to decreasing blood pressure may exaggerate hemodynamic perturbation after a sudden loss of circulating blood volume. In addition, it is possible that patients who have received ETS will show unexpected HR responses after the administration of a vasopressor or vasodilator. We conclude that baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS.
Anesth Analg 2004;98:37-39
http://www.anesthesia-analgesia.org/cgi/content/full/98/1/37

potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak

Thorascopic manipulation of the lung and mediastinal structures may result in cardiac arrhythmias. Electrical current from the cautery may initiate atrial or ventricular tachycardia or fibrillation. Sinus tachycardia may occur secondary to CO2 retention when insufflation techniques are used. A mediastinal shift with compromise of venous return to the heart may initiate a reflex sinus tachycardia. Vagal stimulation and air or CO2 embolism with insufflation techniques may lead to bradycardia or asystole. Hypotension may result from mediastinal tamponade, air or CO2 embolization, or hemorrhage. Hypercarbia, which results from CO2 insufflation, can result in hypertension and tacjycardia. Hemorrhage from the intracostal vessels may occur at the site of trocar placement.
Exposure of the thoracic sympathetic chain requires retraction of the lung apex away from the posterior chest wall. Improper instrumentation and the frequent presence of apical blebs or adhesions may result in a parenchymal lung injury and postoperative pneumothorax or persistent air leak.

The operative procedure and the potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak, inability to complete the procedure thoracoscopically, and death are reviewed with the patient.

Haimovici's Vascular Surgery

Edition: 5, illustrated

Published by Blackwell Publishing, 2004

the heart obeys Starling's law after chemical sympathectomy

This can be seen most dramatically in the case of premature ventricular contraction. The premature ventricular contraction causes early emptying of the left ventricle (LV) into the aorta. Since the next ventricular contraction will come at its regular time, the filling time for the LV increases, causing an increased LV end-diastolic volume. Because of the Frank-Starling law, the next ventricular contraction will be more forceful, causing the ejection of the larger than normal volume of blood, and bringing the LV end-systolic volume back to baseline.

The more the myocardium is dilated, the weaker it can pump, as it then reverts to Laplace's law.
http://en.wikipedia.org/wiki/Frank-Starling_law_of_the_heart

Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue

Differential effects of surgical sympathectomy on rat heart concentrations of neuropeptide Y-immunoreactivity and noradrenaline.

Maccarrone C, Jarrott B.

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.
J Auton Nerv Syst. 1987 Dec;21(2-3):101-7
The aim of this study was to estimate the proportion of cardiac neuropeptide Y-immunoreactivity (NPY-ir) which is not present in sympathetic neurones innervating the rat heart. The procedure employed was to surgically sympathectomize the heart and then measure the remaining cardiac concentrations of NPY-ir and noradrenaline (NA). Unilateral (left) sympathectomy significantly reduced the levels of NPY-ir and NA in all regions of the heart (by 40-70%) except for the NPY-ir in the right atrium which was unaltered. The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy. Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue. In contrast dissimilar changes were produced in the atrium. Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%. These results indicate that approximately half the content of NPY in the right atrium is not present in sympathetic noradrenergic neurones. This pool may occur in the previously described intrinsic neurones of the right atrium.
PMID: 3450689 [PubMed - indexed for MEDLINE]

Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans

Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans
Heart Rhythm, Volume 2, Issue 6, Pages 602-609
J.Moak, B.Eldadah, C.Holmes, S.Pechnik, D.Goldstein

All four patients with bilateral sympathectomy had low septal myocardial 6-[¹⁸F]fluorodopamine-derived radioactivity (2,673 ± 92 nCi-kg/cc-mCi at an average of 89 minutes after injection) compared with normal volunteers (3,634 ± 311 nCi-kg/cc-mCi at 83 minutes, N = 22, P = .007) and higher radioactivity than in patients with pure autonomic failure (1,320 ± 300 nCi-kg/cc-mCi at 83 minutes, N = 7, P = .003). Patients with unilateral sympathectomy had normal 6-[¹⁸F]fluorodopamine-derived radioactivity (3,971 ± 337 nCi-kg/cc-mCi at 87 minutes).

Conclusions

Bilateral upper thoracic sympathectomy partly decreases cardiac sympathetic innervation density.

significantly more cholesterol and total lipids in the aorta after sympathectomy

While the vasomotor effect of the sympathetic nervous system (SNS) on the arterial wall is well recognized, its trophic function is not. It is the aim of these studies to demonstrate this all-important function as it relates to the vascular muscle.

Although the exact mechanism by which sympathetic nerve impulses influence the metabolism of the vessel wall is unknown, effects of sympathectomy can be demonstrated. Several lines of evidence indicate that chronic absence of sympathetic innervation in rabbits increases collagen synthesis and decreases activity of tricarboxylic acid cycle enzymes in the vascular wall. When chemically sympathectomized rabbits were fed a 1% cholesterol dietary supplement for 80 days, the aortas of these rabbits contained significantly more cholesterol and total lipids than those from fully innervated controls in spite of insignificant differences in plasma lipids.

In a subsequent series of experiments we analyzed the efficacy of the SNS in two strains of pigeons. White Carneau (WC) pigeons are known by their susceptibility to atherosclerosis of the aorta while Show Racer (SR) pigeons are not. Our results demonstrate that the abdominal aorta of WC pigeons has less sympathetic innervation and it declines faster with age than that of SR pigeons. The results of the described studies documenting the direct trophic influence of the SNS on the arterial wall are reinforced by the similarity to the vessel wall changes induced by partial sympathectomy and natural aging.

Trophic effect of the sympathetic nervous system on vascular smooth muscle

	Annals of Biomedical Engineering
	Springer Netherlands
ISSN	0090-6964 (Print) 1573-9686 (Online)
Issue	Volume 11, Number 6 / November, 1983

Causes of Orthostatic Hypotension

Peripheral

Amyloidosis

Diabetic, alcoholic, or nutritional neuropathy

Familial dysautonomia (Riley-Day syndrome)

Guillain-Barré syndrome

Paraneoplastic syndromes

Pure autonomic failure (formerly called idiopathic orthostatic hypotension)

Surgical sympathectomy

http://www.merckmanuals.com/professional/sec07/ch069/ch069d.html

sympathectomy suppressed the baroreflex control of heart rate during pressor and depressor tests in patients with palmar or axillary hyperhidrosis

We conclude that baroreflex responses are suppressed in patients who receive ETS.

Anesth Analg. 2004 Jan;98(1):37-9, table of contents.Click here to read

PMID: 14693579 [PubMed - indexed for MEDLINE]

interrupting sympathetic efferent fibers innervating the heart and baroreflex

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Baroreflex control of heart rate during cardiac sympathectomy by epidural anesthesia in lightly anesthetized humans.

Dohi S, Tsuchida H, Mayumi T
Anesth Analg 1983; 62:815-20.

Baroreflex sensitivity, measured as cardiac acceleration in response to nitroglycerin, was significantly lower (p < style="font-weight: bold;">The results suggest that baroreflex-mediated response to decreases in arterial pressure is dependent on the integrity of the sympathetic nervous system.

Baroreflex control of heart rate during high thoracic epidural anaesthesia. A randomised clinical trial on anaesthetised humans.
Goertz A, Heinrich H, Seeling W
Anaesthesia 1992; 47:984-7.

Bilateral sympathectomy produced fatal heart block in a few of their experiments

Mendlowitz. Schauer, and Gross⁴ pointed out that the heart rate became slower after removal of the sympathetic chain, but this bradycardia was only temporary. Bilateral sympathectomy produced fatal heart block in a few of their experiments.

American Heart Journal
Volume 22, Issue 4, October 1941, Pages 545-548

bradycardia and other cardiac complications are common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear.

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

Sympathectomy: "suppression of the neuroendocrine stress response"

p.254

Neuraxial blocks typically produce variable decrease in blood pressure that might be accompanied by a decrease in heart rate and cardiac contractility. These effects are generally proportional to the degree (level) of the sympathectomy. Vasomotor tone is primarily determined by sympathetic fibres arising from T5 to L1, innervating arterial and venous smooth muscle. Blocking these nerves causes vasodilation of the venous capacitance vessels, pooling of blood, and decreased vvenous terurn to the heart; in some instances, arterial vasodilation may also decrease systemic vascular resistance. The effects of arterial vasodilation may be minimized by compensatory vasoconstriction above the level of the block. A high sympathetic block not only prevents compensatory vasoconstriction but also blocks the sympathetic cardiac accelerator fibres that arise at T1-T4.
Profound hypotension may result from vasodilation combined with bradycardia and decreased contractility. These effects are further exaggerated if venous return is further compromised by a head-up position or from the weight of a gravid uterus. Unopposed vagal tone in some persons may explain cardiac arrest with spinal anesthesia.
p.261

The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss off this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.
p.375

AV conduction abnormalities are usually manifested by abnormal ventricular depolarization (bundle-branch block) prolongation of the P-R interval (first degree AV block) failure of some atrial impulses to depolarize the ventricles (second degree AV block) or AV dissociation (third degree AV block or complete heart block).
p.428

Clinical anesthesiology By G. Edward Morgan, Maged S. Mikhail, Michael J. Murray
McGraw-Hill, Edition: 3 - 2002

Surgical sympathectomy listed as neurologic disorder

Other neurologic disorders
- Idiopathic orthostatic hypotension
- Multiple sclerosis
- Parkinsonism
- Posterior fossa tumor
- Shy-Drager syndrome
- Spinal cord injury with paraplegia
- Surgical sympathectomy
- Syringomyelia
- Syringobulbia
- Tabes dorsales (syphillis)
- Wernicke's encephalopathy
Dizziness: Classification and Pathophysiology
The Journal of Manual and Manipulative Therapy, Vol. 12, No 4 (2004)

inhibition of sympathetic activity and a possible impairment of endothelial function

Alterations in skin microcirculation induced by brachial plexus block can be evaluated by wavelet transform of the laser Doppler flowmetry signal. Brachial plexus block reduces the oscillatory components within the 0.0095- to 0.021- and 0.021- to 0.052-Hz intervals of the perfusion signal. These alterations are related to inhibition of sympathetic activity and a possible impairment of endothelial function.

Anesthesiology:

September 2006 - Volume 105 - Issue 3 - pp 478-484

Clinical Investigations

Endothelial dysfunction, or the loss of proper endothelial function, is a hallmark for vascular diseases, and often leads to atherosclerosis.
http://en.wikipedia.org/wiki/Endothelium

increased sensitivity to adrenaline is produced by sympathectomy alone

"The increased sensitivity to adrenaline is produced by sympathectomy alone. I think sensory denervation makes no difference."

Vascular Reactivity Following Sympathectomy

Chapter Author: R. T. Grant

Ciba Foundation Symposium - Peripheral Circulation in Man

Book Series: Novartis Foundation Symposia

Published Online: 27 May 2008

Editor(s): G. E. W. Wolstenholme, Jessie S. Freeman

Print ISBN: 9780470714706 Online ISBN: 9780470715185

haemodynamic instability during surgery

Rapid and excessive carbon dioxide insufflation into the closed chest cavity may create a tension pneumopthorax, displace the mediastinum, and compress the lungs and great vessels with consequent haemodynamic instability. During carbon dioxide insufflation using endobronchial intubation, Hartrey and colleagues reported a decrease in systolic arterial pressure of > 20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In common with other surgical procedures, routine monitoring during thorascopic sympathectomy should include ECG, pulse oximetry and capnography. However, during thorascopic surgery, SpO2 and end-tidal carbon dioxide have the additional function of monitoring the surgical technique.
BJA 1997;79: 113-119

supersensitivity to sympathomimetic amines in the chronically denervated heart

http://www.ncbi.nlm.nih.gov/pubmed/2988820?dopt=Abstract

bilateral ETS causes the suppression of cardiovascular response to exercise

HR and BP at rest and cardiovascular response to exercise were similar in patients with palmar hyperhidrosis before ETS and in the normal control population. Therefore, we consider that patients with palmar hyperhidrosis have no overactivity of the sympathetic nerve. However, because bilateral ETS causes the suppression of cardiovascular response to exercise, patients that has been treated with ETS need to be observed during high-level exercise.

http://iars.org/abstracts/browsefile/browse.asp?command=N&absnum=45&dir=S190

lead to hyperfunction of the serotoninergic system and pathology

We studied the balance of activity of sympathetic, parasympathetic, and serotoninergic divisions of the autonomic nervous system in the regulation of the heart function in rabbits. High activities of the sympathetic and parasympathetic system are associated with antagonistic interactions between them. Moderation of activity of these systems could be accompanied by activation of the serotoninergic system. Physiological sympathectomy and parasympathectomy lead to hyperfunction of the serotoninergic system and pathology.

Bulletin of Experimental Biology and Medicine, Vol. 140, No. 5, 2005 PHYSIOLOGY

significant decrease of MAP, cardiac arrythmia, cardiac arrest and hypoxemia - complications of ETS surgery

Together, these findings suggest that peripheral sympathetic denervation may modulate immune function via activation of the hypothalamic-pituitary-adrenal (HPA) axis.

Ann N Y Acad Sci. 2000;917:923-34.

Risk of bradycardia after endoscopic electrocautery of the upper thoracic sympathetic ganglia

We evaluated risk of bradycardia after endoscopic electrocautery of the upper thoracic sympathetic ganglia (ETS). Enrolled in this study were 24 patients. Bradycardia, defined as heart rate below 50 beats per min continuing for more than 5 min, was found in 12 patients (50%). All patients were divided into two groups; bradycardia group and non-bradycardia group. Age, sex, region of electrocautery, fentanyl dosage, and operation time were not different between the two groups. Power spectral analysis of heart rate variability revealed that sympathetic activity decreased after ETS. Multivariate analysis indicates that postoperative-minimal heart rate depends upon preoperative heart rate at rest.
http://www.ncbi.nlm.nih.gov/pubmed/10885235

prolongation of the isometric (tension) period (TP) of the left ventricle occurred in the majority (72 per cent) of all cases after sympathectomy

The prolongation of the isometric (tension) period (TP) of the left ventricle which occurred in the majority (72 per cent) of all cases after unilateral or bilateral transthoracic sympathectomy (without or with unilateral or bilateral transthoracic splanchnicotomy) indicates a diminution of inotropic cardiac action. It can be assumed to correspond to the cholinergic (vagal) preponderance which results from a partial or complete sympathetic denervation of the heart. Reduction of the pulse pressure oc-
curred in 56 per cent of the cases, probably due to the same mechanism.

www.chestjournal.org/content/38/4/423.full.pdf
by W RAAB - 1960

blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility

The CEA (Cervical Epidural Anaesthesia) blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required.
Ann Fr Anesth Reanim. 1993;12(5):483-92.
PMID: 8311355 [PubMed - indexed for MEDLINE

Long-Term Denervation of Vascular Smooth Muscle Causes Not Only Functional but Structural Change

Rosemary D. Bevan, Hiromichi Tsuru

Department of Pharmacology, School of Medicine, University of California, Los Angeles, Calif.

Address of Corresponding Author

Blood Vessels 1979;16:109-112 (DOI: 10.1159/000158197)

sympathectomy leads to peripheral vasodilation, reduced preload, and subsequently decreased cardiac output

Despite a duration of only 2 week, repeated IVRS (intravenous regional sympathetic block) efferent blocks are an attractive alternative to the higher-risk techniques of thoracic sympathetic block and thoracic surgical or thoracoscopic sympathectomy. (p. 848)

Table 42-1
Classification of percutaneous neural destructive procedures:
Anatomy
1. Peripheral neurotomy (such as destruction of intercostal, ilioinguinal nerves)
2. Rhizotomy (spinal dorsal root rhizotomy, trigeminal rhizotomy)
3. Destruction of sensory pathways in the spinal cord (midline punctuate myelotomy, cordotomy)
4. destruction of brain sensory centers (hypophysectomy)
5. Sympathectomy
(p.992)

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker

Wolters Kluwer Health
Edition: 4 - 2008

Acquired cardiovascular disease following Sympathectomy

Effects of endoscopic thoracic sympathectomy for primary hyperhidrosis on cardiac autonomic nervous activity

We found statistically significant differences (P < .05) in both time and frequency domains. Parameters that evaluate global cardiac autonomic activity (total power, SD of normal R-R intervals, SD of average normal R-R intervals) and vagal activity (rhythm corresponding to percentage of normal R-R intervals with cycle greater than 50 ms relative to previous interval, square root of mean squared differences of successive normal R-R intervals, high-frequency power, high-frequency power in normalized units) were statistically significantly increased after sympathectomy. Low-frequency power in normalized units, reflecting sympathetic activity, was statistically significantly decreased after sympathectomy. Low-/high-frequency power ratio also showed a significant decrease, indicating relative decrease in sympathetic activity and increase in vagal activity.

The Journal of Thoracic and Cardiovascular Surgery
Volume 137, Issue 3, March 2009, Pages 664-669

Influence of thoracic sympathectomy on cardiac induced oscillations in tissue blood volume

The parameter AM/BL is proportional to the cardiac-induced blood volume increase, which depends on the arterial wall compliance. AM/BL increased after the thoracic sympathectomy treatment (for male patients, from 2.60 ± 1.49% to 4.81 ± 1.21%), as sympathetic denervation decreases arterial tonus in skin. The very low-frequency (VLF) fluctuations of BL or AM showed high correlation (0.90 ± 0.11 and 0.92 ± 0.07, respectively) between the right and left hands before the thoracic sympathectomy, and a significant decrease in the right-left correlation coefficient (to 0.54 ± 0.22 and 0.76 ± 0.20, respectively) after the operation. The standard deviation of the BL or AM VLF fluctuations also reduced after the treatment, indicating sympathetic mediation of the VLF PPG fluctuations. The study also shows that the analysis of the PPG signal and the VLF fluctuations of the PPG parameters enable the assessment of the change in sympathetic nervous system activity after thoracic sympathectomy.
http://cat.inist.fr/?aModele=afficheN&cpsidt=14106877

sympathectomy will blunt the normal tachycardic response to hypovolemia

Spinal or epidural analgesia may cause a sympathectomy that will blunt the normal tachycardic response to hypovolemia.
OBSTETRIC ANAESTHESIA OUR WAY
Royal Women's Hospital Melbourne
Author: Dr Philip Popham

significant adverse effects on cardiopulmonary physiology

Because of technologic advances and improved postoperative recovery, endoscopic surgery has become the technique of choice for many thoracic surgical procedures^{6 and 25}; however, endoscopic visualization of intrathoracic structures requires retraction or collapse of the ipsilateral lung, which can have significant adverse effects on cardiopulmonary physiology. These cardiopulmonary changes can be further affected by the pathophysiologic changes associated with the disease process requiring the surgical procedure.

Because acute changes in cardiopulmonary function can compromise patient safety severely, a clear understanding of the dynamic interaction between the anesthetic–surgical technique and patient physiology is essential. This article discusses the effect of thoracoscopic surgery and the impact of various anesthetic interventions on cardiovascular and pulmonary physiology. In addition, some recommendations for “damage control” are made.

Anesthesiology Clinics of North America
Volume 19, Issue 1, 1 March 2001, Pages 141-152

Pacemaker after T2 Sympathectomy

A 23-year-old woman with craniofacial hyperhidrosis underwent bilateral thoracoscopic T2-sympathectomy. Marked sinus bradycardia with a mean heart rate of 49 beats/min by Holter ECG monitoring occurred after the procedure and persisted for > 2 years. Normal sinus node function was found by an invasive electrophysiological study and unopposed vagotonia after sympathectomy was diagnosed. A permanent pacemaker was implanted. Although reduced heart rate is a common phenomenon after bilateral dorsal sympathectomy, intractable bradycardia with permanent pacing is rare. This patient demonstrates one of the potential cardiac complications of bilateral sympathectomy.

Pacing and Clinical Electrophysiology

Volume 24 Issue 4 Page 524-525, April 2001

sympathectomy decreased cardiac sympathetic nerve density and norepinephrine level

Cardiac sympathetic innervation was visualized by means of a glyoxylic catecholaminergic histofluorescence method. Transient outward current (I-to) of ventricular myocytes was recorded with the whole-cell configuration of the patch clamp technique. We observed that sympathectomy (i) decreased cardiac sympathetic nerve density and norepinephrine level, (ii) reduced the protein expression of Kv4.2, Kv1.4, and Kv channel-interacting protein 2 (KChIP2), (iii) decreased current densities and delayed activation of I-to channels, (iv) reduced the phosphorylation of extracellular signal-regulated kinase 1 and 2 (ERK1/2) and cAMP response element-binding protein (CREB), and (v) increased the severity of ventricular fibrillation induced by rapid pacing.
Heart Disease Weekly. Atlanta: Dec 28, 2008. pg. 54

Patients may develop bradycardia after surgical procedure

Upper-Thoracic Sympathectomy;
Patients may develop bradycardia after surgical procedure
Heart Disease Weekly. Atlanta: Feb 23, 2003. pg. 71

Cardiac hypertrophy accelerated by left cervical sympathectomy

Cardiac hypertrophy in spontaneously hypertensive rats was accelerated by denervation of the left cervical sympathetic ganglia. Supersensitivity due to denervation may also exist in cardiac muscles.

	Biomedical and Life Sciences
SpringerLink Date	Tuesday, August 02, 2005