Anesthesiol Res Pract. 2013;2013:413985. doi: 10.1155/2013/413985. Epub 2013 Oct 23.

Supraventricular arrhythmias after thoracotomy: is there a role for autonomic imbalance?

Vretzakis G1, Simeoforidou M, Stamoulis K, Bareka M.

Author information

Abstract

Supraventricular arrhythmias are common rhythm disturbances following pulmonary surgery. The overall incidence varies between 3.2% and 30% in the literature, while atrial fibrillation is the most common form. These arrhythmias usually have an uneventful clinical course and revert to normal sinus rhythm, usually before patent's discharge from hospital. Their importance lies in the immediate hemodynamic consequences, the potential for systemic embolization and the consequent long-term need for prophylactic drug administration, and the increased cost of hospitalization. Their incidence is probably related to the magnitude of the performed operative procedure, occurring more frequently after pneumonectomy than after lobectomy. Investigators believe that surgical factors (irritation of the atria per se or on the ground of chronic inflammation of aged atria), direct injury to the anatomic structure of the autonomic nervous system in the thoracic cavity, and postthoracotomy pain may contribute independently or in association with each other to the development of these arrhythmias. This review discusses currently available information about the potential mechanisms and risk factors for these rhythm disturbances. The discussion is in particular focused on the role of postoperative pain and its relation to the autonomic imbalance, in an attempt to avoid or minimize discomfort with proper analgesia utilisation.

http://www.ncbi.nlm.nih.gov/pubmed/24235971

"Since changes in old age show some similarities with those following chronic sympathectomy"

"For the tracheobronchial tree. surgical (sympathectomy) and chemical (with 6-hydroxydopamine or reserpine) interventions lead to histological disappearance of the NA and NPY." (p.435)

" Prejunctional supersensitivity to norepinephrine after sympathectomy or cocaine treatment." (p. 410)

"Following chronic sympathectomy, substance P expression in presumptive sensory nerves....and NPY-expression in parasympathetic nerves ...to autonomically innervated tissues have both been shown to increase... Experiments using NGF and anti-NGF antibodies (Kessler et al., 1983) have suggested that competition between sympathetic and sensory fibers for target-derived growth factors could explain these apparently compensatory interactions,..." (p. 33)

"Since changes in old age show some similarities with those following chronic sympathectomy, it is tempting to consider whether alterations in one group of nerves in tissues with multiple innervations trigger reciprocal changes in other populations of nerves, perhaps through the mechanism of competition for common, target-produced growth factors. The nature of these changes is such that they could be nonadaptive and even destabilizing of cardiovascular homeostasis. (p. 34) 

Impairment of sympathetic and neural function has been claimed in cholesterol-fed animals (Panek et al., 1985). It has also been suggested that surgical sympathectomy may be useful in controlling atherosclerosis in certain arterial beds (Lichter et al., 1987). Defective cholinergic arteriolar vasodilation has been claimed in atherosclerotic rabbits (Yamamoto et al., 1988) and, in our laboratory, we have recently shown impairment of response to perivascular nerves supplying the mesenteric, hepatic, and ear arteries of Watanabe heritable hyperlipidemic rabbits (Burnstock et al., 1991). 
   Loss of adrenergic innervation has been reported in alcoholism (Low et al., 1975), amyloidosis (Rubenstein et al., 1983), orthostatic hypotension (Bannister et al., 1981), and subarachnoid haemorrhage (Hara and Kobayashi, 1988). Recent evidence shows that there is also a loss of noradrenergic innervation of blood vessels supplying malignant, as compared to benign, human intracranial tumours (Crockard et al., 1987). (p. 14)  

Vascular Innervation and Receptor Mechanisms: New    Perspectives 

Rolf Uddman

Academic Press, 2 Dec 2012 - Medical - 498 pages

Our data confirmed that sympathectomy in patients with EPH results in a disturbance of bronchomotor tone and cardiac function

Our study was composed of patients affected by EH, and

thus having a dysfunction of sympathetic activity. The

observed respiratory and clinical effects would probably not

be observed in healthy individuals.

(ii) The cardio-respiratory effects were observed 6 months after

operation. However, a longer postoperative period would

be required to determine if they are long-term effects.

(iii) The number of patients was too limited, thus our results

should be corroborated by larger studies.

CONCLUSION

Our data confirmed that sympathectomy in patients with

EPH results in a disturbance of bronchomotor tone and

cardiac function.

1. 
   
   

   Eur J Cardiothorac Surg (2012)

   doi: 10.1093/ejcts/ezs071

dennervation sensitization increases the arrhythmia susceptibility - Baker Medical Research Institute

The NA content in the heart was not measured but it is likely to be small at least at the 10-day period. It is known that three days after chemical sympathectomy NA content is only 7% of normal value [6]. Second, the development of adrenoceptor supersensitivity in the transplanted heart was demonstrated clearly with enhanced heart rate responses to NA or propranolol (at Day 10) [1]. As dennervation sensitization increases the arrhythmia susceptibility [6], it is thus possible that, in the presence of receptor supersensitivity, adrenergic activation occurs by either increase in circulating catecholamines and possibly local release of residual NA, which might still have been sufficient to contribute to arrhythmia development.
Role of sympathoadrenergic mechanisms in arrhythmogenesis
Xiao-Jun Du* and Anthony M. Dart
Baker Medical Research Institute, Melbourne, Victoria, Australia 
Cardiovascular Research 1999 43(4):832-834;

bradycardia and other cardiac complications are common following surgery to treat palmar hyperhidrosis and blushing

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. (2009)

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

"decrease in cardiac output causing a decrease in cerebral perfusion"

Orthostatic syncope can occur after a spinal cord injury or sympathectomy

Neurocardiogenic syncope is also referred to as vasovagal, vasodepressor, neurally mediated, and reflex syncope. As the name implies, neurocardiogenic syncope involves the interaction of various autonomic nervous system reflexes, the central nervous system, and the cardiovascular system..sup.1,4,12-14 The Bezold-Harisch reflex is cited as the mechanism responsible for vasovagal syncope and has two components. There is "cardio-inhibitory syncope" due to a vagal (parasympathetic) mediated reflex causing bradycardia or even asystole, plus "vasodepressor syncope" from withdrawal of sympathetic input leading to a drop in PVR with venous pooling in the periphery leading to hypotension.

Vasovagal syncope can occur in heart transplant patients, suggesting that the Bezold-Harisch reflex or vagal stimulation plus sympathetic withdrawal as the only factor may be a somewhat simplistic explanation, and that other variables may also play a role.

Although there are many causes of cardiovascular syncope, the final common mechanism is a decrease in cardiac output causing a decrease in cerebral perfusion.
Orthostatic syncope can occur after a spinal cord injury or sympathectomy, which eliminates
the vasopressor reflexes, and in patients on certain medications, commonly antihypertensive and
vasodilator drugs.
http://www.thefreelibrary.com/Syncope+in+Pediatric+Patients-a0217945432

"Similar low values are observed in patients with sympathectomy and in patients with tetraplegia"

"Patients with progressive autonomic dysfunction (including diabetes) have little or no increase in plasma noradrenaline and this correlates with their orthostatic intolerance (Bannister, Sever and Gross, 1977). In patients with pure autonomic failure, basal levels of noradrenaline are lower than in normal subjects (Polinsky, 1988). Similar low values are observed in patients with sympathectomy and in patients with tetraplegia. (p.51)



The finger wrinkling response is abolished by upper thoracic sympathectomy. The test is also abnormal in some patients with diabetic autonomic dysfunction, the Guillan-Barre syndrome and other peripheral sympathetic dysfunction in limbs. (p.46)

Other causes of autonomic dysfunction without neurological signs include medications, acute autonomic failure, endocrine disease, surgical sympathectomy . (p.100) 




Anhidrosis is the usual effect of destruction of sympathetic supply to the face. However about 35% of patients with sympathetic devervation of the face, acessory fibres (reaching the face through the trigeminal system) become hyperactive and hyperhidrosis occurs, occasionally causing the interesting phenomenon of alternating hyperhidrosis and Horner's Syndrome (Ottomo and Heimburger, 1980). (p.159)



Disorders of the Autonomic Nervous System
By David Robertson, Italo Biaggioni
Edition: illustrated
Published by Informa Health Care, 1995
ISBN 3718651467, 9783718651467"

Low HRV is a risk factor for pathophysiology and psychopathology

http://www.ncbi.nlm.nih.gov/pubmed/18771686

lower HRV and elevated norepinephrine have been associated with a number of adverse health outcomes

	Fagundes, Christopher P.1 Murray, David M.2 Hwang, Beom Seuk1,3 Gouin, Jean-Philippe1,4 Thayer, Julian F.4,5 Sollers, John J.6 Shapiro, Charles L.7 Malarkey, William B.1,7,8,9 Kiecolt-Glaser, Janice K.1,9,10 kiecolt-glaser.1@osu.edu
	Psychoneuroendocrinology. Sep2011, Vol. 36 Issue 8, p1137-1147. 11p.

HRV and mood disorders

Int J Psychophysiol. 2013 Sep;89(3):288-96. doi: 10.1016/j.ijpsycho.2013.06.018. Epub 2013 Jun 22.

The relationship between mental and physical health: insights from the study of heart rate variability.

Kemp AH1, Quintana DS.

Author information

• 1SCAN Research & Teaching Unit, School of Psychology, University of Sydney, Australia; Discipline of Psychiatry, University of Sydney, Australia; Hospital Universitário, University of São Paulo, São Paulo, Brazil. Electronic address: andrew.kemp@sydney.edu.au.

Abstract

Here we review our recent body of work on the impact of mood and comorbid anxiety disorders, alcohol dependence, and their treatments on heart rate variability (HRV), a psychophysiological marker of mental and physical wellbeing. We have shown that otherwise healthy, unmedicated patients with these disorders display reduced resting-state HRV, and that pharmacological treatments do not ameliorate these reductions. Other studies highlight that tricyclic medications and the serotonin and noradrenaline reuptake inhibitors in particular may have adverse cardiovascular consequences. Reduced HRV has important functional significance for motivation to engage social situations, social approach behaviours, self-regulation and psychological flexibility in the face of stressors. Over the longer-term, reduced HRV leads to immune dysfunction and inflammation, cardiovascular disease and mortality, attributable to the downstream effects of a poorly functioning cholinergic anti-inflammatory reflex. We place our research in the context of the broader literature base and propose a working model for the effects of mood disorders, comorbid conditions, and their treatments to help guide future research activities. Further research is urgently needed on the long-term effects of autonomic dysregulation in otherwise healthy psychiatric patients, and appropriate interventions to halt the progression of a host of conditions associated with morbidity and mortality.

noradrenaline loss in the sympathetic nervous system of the heart

Symptoms or signs of abnormal autonomic nervous system function occur commonly in several neurological disorders.
Clinical evaluations have depended on physiological, pharmacological, and neurochemical approaches. Recently, imaging of sympathetic noradrenergic innervation has been introduced and applied especially in the heart. Most studies have used the radiolabeled sympathomimetic amine, (123)I-metaiodobenzylguanidine. Decreased uptake or increased "washout" of (123)I-metaiodobenzylguanidine-derived radioactivity is associated with worse prognosis or more severe disease in hypertension, congestive heart failure, arrhythmias, and diabetes mellitus. This pattern may reflect a high rate of postganglionic sympathetic nerve traffic to the heart. Many recent studies have agreed on the remarkable finding that all patients with Parkinson's disease and orthostatic hypotension have a loss of cardiac sympathetic innervation, whereas all patients with multiple system atrophy, often difficult to distinguish clinically from Parkinson's disease, have intact cardiac sympathetic innervation. Because Parkinson's disease entails a postganglionic sympathetic noradrenergic lesion, the disease appears to be not only a movement disorder, with dopamine loss in the nigrostriatal system of the brain, but also a dysautonomia, with noradrenaline loss in the sympathetic nervous system of the heart. As new ligands are developed, one may predict further discoveries of involvement of components of the autonomic nervous system in neurological diseases.
Semin Neurol. 2003 Dec;23(4):423-33.

Left thoracoscopic sympathectomy for cardiac denervation in patients with life-threatening ventricular arrhythmias

J Thorac Cardiovasc Surg. 2014 Jan;147(1):404-9. doi: 10.1016/j.jtcvs.2013.07.064. Epub 2013 Oct 24.

Sixteen (73%) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55%) becoming completely arrhythmia free after sympathectomy. Six (27%) of the patients were nonresponsive to treatment; each had persistent symptoms at follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/24268954

Guidelines for the diagnosis and management of Catecholaminergic Polymorphic Ventricular Tachycardia - Australia, 2011

Left cervical sympathectomy:
Selective left cervical sympathectomy, which can now be done thoracoscopically, may be considered for: 1. Patients in whom beta blockers are contra-indicated or not adhered to
2. An AICD cannot be placed or is not wanted.
3. Recurrent VT in those with an AICD despite maximal medical treatment 13-15.

The Cardiac Society of Australia and New Zealand, 2011

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 occurred in 56 per cent of the cases, probably due to the same mechanism.

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

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^6and 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

Regional cerebral blood flow correlates with heart period and high-frequency heart period variability

Psychophysiology. 2004 Jul;41(4):521-30.

Regional cerebral blood flow correlates with heart period and high-frequency heart period variability during working-memory tasks: Implications for the cortical and subcortical regulation of cardiac autonomic activity.

Gianaros PJ1, Van Der Veen FM, Jennings JR.

Author information

Erratum in

• Psychophysiology. 2004 Sep;41(5):807.

Abstract

The aim of the present study was to characterize the functional relationships between behaviorally evoked regional brain activation and cardiac autonomic activity in humans. Concurrent estimates of regional cerebral blood flow (rCBF; obtained by positron emission tomography), heart period, and high-frequency heart period variability (HF-HPV; an indicator of cardiac parasympathetic activity) were examined in 93 adults (aged 50-70 years) who performed a series of increasingly difficult working-memory tasks. Increased task difficulty resulted in decreased heart period (indicating cardioacceleration) and decreased HF-HPV (indicating decreased cardiac parasympathetic activity). Task-induced decreases in heart period and HF-HPV were associated with concurrent increases and decreases in rCBF to cortical and subcortical brain regions that are speculated to regulate cardiac autonomic activity during behavioral processes: the medial-prefrontal, insular, and anterior cingulate cortices, the amygdala-hippocampal complex, and the cerebellum. These findings replicate and extend a small number of functional neuroimaging studies that suggest an important role for both cortical and subcortical brain systems in human cardiac autonomic regulation.

http://www.ncbi.nlm.nih.gov/pubmed/15189475

change in sympathetic nervous system activity after thoracic sympathectomy

The photoplethysmographic (PPG) signal, which measures cardiac-induced changes in tissue blood volume by light transmission measurements, shows spontaneous fluctuations. In this study, PPG was simultaneously measured in the right and left index fingers of 16 patients undergoing thoracic sympathectomy, and, from each PPG pulse, the amplitude of the pulse (AM) and its maximum (BL) were determined. 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.

Medical and Biological Engineering and Computing

2001, Volume 39, Issue 5, pp 579-583
http://link.springer.com/article/10.1007%2FBF0234514

Bilateral surgical sympathectomy provides a valuable tool for future investigations of the cellular basis of supersensitivity in the myocardium.

K Goto, PA Longhurst, LA Cassis, RJ Head, DA Taylor, PJ Rice and WW Fleming

Volume 234, Issue 1, pp. 280-287, 07/01/1985
Copyright © 1985 by American Society for Pharmacology and Experimental Therapeutics

The Effects of Thoracic Sympathotomy on Heart Rate Variability in Patients with Palmar Hyperhidrosis

Compared with preoperative variables, there was a significant increase in the number of adjacent normal R wave to R wave (R- R) intervals that differed by more than 50 ms, as percent of the total number of normal RR intervals (pNN50); root mean square difference, the square root of the mean of the sum of squared differences between adjacent normal RR intervals over the entire 24-hour recording; standard deviation of the average normal RR in- terval for all 5-minute segments of a 24-hour recording (SDANN) after thoracic sympathotomy. Low frequencies (LF, 0.04 to 0.15 Hz) decreased significantly.
Yonsei Med J 53(6):1081-1084, 2012

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481380/pdf/ymj-53-1081.pdf 

Patients with surgical sympathectomies have low plasma levels of DA and NE [49], whereas EPI:NE ratios are increased

Patients with surgical sympathectomies have low plasma levels of DA and NE [49], whereas EPI:NE ratios are increased (unpublished observations), suggesting decreased sympathetically mediated exocytosis and compensatory adrenomedullary activation.

Catecholamines 101, David S. Goldstein
Clin Auton Res (2010) 20:331–352

QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later - significant change after sympathectomy

The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later.

http://www.sciencedirect.com/science/article/pii/S0167527399001011

Functional and organic vascular wall changes after sympathectomy and partial nerve damage

Langenbecks  

Arch  

Klin  

Chir  

Ver  

Dtsch  

Z  

Chir.  

1959;;291:217-31. 

sympathectomy and parasympathectomy 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

Decrease in basal heart rate, norepinephrine level after sympathectomy

Endoscopic thoracic sympathectomy – its effect in the treatment of refractory angina pectoris

Interact CardioVasc Thorac Surg (2006) 5 (4): 464-468. 

Martin Striteskya, Milos Dobiasa, Rudolf Demesb, Michal Semradc,*, Eva Poliachovaa, Tomas Cermaka, Jiri Charvatd and Ivan Maleke
Author Affiliations
*Corresponding author. Tel.: +420224962781; fax: +420224922695. E-‐‑mail address:

+

↵

semradvfn@hotmail.com (M. Semrad).
Abstract

Received September 16, 2005. Revision received February 12, 2006. Accepted March 13, 2006.

Objective: To document an improvement in the quality of life in a group of patients with refractory angina and videothoracoscopic sympathectomy (VTSY) during the early postoperative period and a six-‐‑month follow-‐‑up. Methods: Ten patients with angina CCS IV refractory to a conventional therapy underwent VTSY between the years 1998 and 2002 at our institution. All patients underwent a complex preoperative evaluation, including pain assessment using a visual analog scale (VAS). Proximal thoracic sympathetic blockage was performed in all patients as a diagnostic test. The resection of bilateral Th2-‐‑Th4 ganglions was performed under general anesthesia and selective lung ventilation. All patients were monitored 6 months after the VTSY. Results: No deaths occurred in our group of patients, with an average hospital stay of
4.1 days. Nine of the ten operated patients referred an important subjective relief of pain. There was a drop from 10 to 4 according to VAS (P<0.05), and from 4 to 2.4 according to CCS (P<0.05). Decreases in basal heart rate, norepinephrine level, and an occurrence of ventricular premature beats reached the level of statistical significance. Conclusions: The increasing number of patients with refractory angina prompted a search for an effective and safe therapy to improve the quality of their life. New evidence in the pathophysiology of an ischemic myocardium and investigation of the impact of thoracic sympathectomy suggests sympathetic denervation seems to be a possible alternative method for the treatment of refractory angina pectoris. 

Long-term effect of endoscopic transthoracic s... [Int J Cardiol. 1999] - PubMed - NCBI

Long-term effect of endoscopic transthoracic s... [Int J Cardiol. 1999] - PubMed - NCBI: "We evaluated short and long-term effects on QT dispersion and autonomic balance after endoscopic transthoracic sympathicotomy (ETS). Heart rate variability (HRV) reflects autonomic balance of the heart. QT dispersion is a marker of cardiac electrical instability in patients with ischemic heart disease. Holter recordings for 24 h and a twelve-lead ECG were made prior to, 1 month, 1 year and 2 years after ETS. HRV was analysed in time domain and spectral analysis was performed during controlled respiration in supine position and during head up tilt. Dispersion of QT time and QTc were calculated. Of 88 patients, 62 (60) were eligible for HRV (QT-dispersion) analysis after 1 month, 39 (38) patients after 1 year and 23 (24) patients after 2 years. The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later."

lowering of heart rate and blood pressure, decreased responsiveness of the cardiocirculatory system to emotional stimuli after sympathectomy

"lowering of heart rate and blood pressure, decreased responsiveness of the cardiocirculatory system to emotional stimuli: it is an effect that is especially noticeable in patients operated on for erythrophobia and less evident in those operated for hyperhidrosis. It is almost always a welcome phenomenon, which contributes considerably to the feeling of tranquility and serenity that generally supersedes anxiety. Excessive reduction in blood pressure or heart rate may lead to a state of weakness and fatigue that may require removal of the clips in approx. 2%. This rare state of asthenia contrasts with the increased energy and vigor that most patients experience when they feel freed from overwhelming anxiety."    

"The neurovegetative nervous system is, however, very dynamic and tends to adapt continuously during lifetime to all environmental or organic changes and conditions. Therefore, it reacts very individually when a reflex circuit has been blocked. The resulting side effects cannot be predicted in detail, and though they in most patients are relatively mild or even absent, there is a small group of patients developing heavy side effects. Therefore, surgery should only be considered in carefully selected cases in whom non-invasive treatment has failed and in whom the detrimental consequences of erythrophobia regarding the psychosocial situation and the quality of life is such to justify more adverse side effects. It should also always be kept in mind that therapy can be ineffective and that, in the long term, 10-15% of patients do not consider themselves satisfied with the result of surgery. In any case, the author prefers the use of a potentially reversible surgical technique (ESB), instead of destructive techniques (cutting, coagulation, removal of ganglia)."  

http://www.chir.it/en_erythrophobia.php

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 occurred in 56 per cent of the cases, probably due to the same mechanism.

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

significant associations between heart rate and regional cerebral blood flow

Neurosci Biobehav Rev. 2012 Feb;36(2):747-56. doi: 10.1016/j.neubiorev.2011.11.009. Epub 2011 Dec 8.

A meta-analysis of heart rate variability and neuroimaging studies: implications for heart rate variability as a marker of stress and health.

The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model and update it with recent results. Specifically, we performed a meta-analysis of recent neuroimaging studies on the relationship between heart rate variability and regional cerebral blood flow. We identified a number of regions, including the amygdala and ventromedial prefrontal cortex, in which significant associations across studies were found. We further propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. Heart rate variability may provide an index of how strongly 'top-down' appraisals, mediated by cortical-subcortical pathways, shape brainstem activity and autonomic responses in the body. If the default response to uncertainty is the threat response, as we propose here, contextual information represented in 'appraisal' systems may be necessary to overcome this bias during daily life. Thus, HRV may serve as a proxy for 'vertical integration' of the brain mechanisms that guide flexible control over behavior with peripheral physiology, and as such provides an important window into understanding stress and health.

http://www.ncbi.nlm.nih.gov/pubmed/22178086

CARDIOVASCULAR CHANGES POST SYMPATHECTOMY

Short- and Long-term Effects

Pulse rates taken at rest and after effort were significantly
lower than those taken after operation, and the blood pressure
response to exercise was blunted. ECG tracings showed a sig-
nificant change in the electrical frontal plane axis and shortening
of the QTc interval.


Tel-Hashomer, and Tel Aviv University Sackler Medical
School, Tel Aviv, Israel, and the National Heart,
Lung, Blood Institute, National Institutes of Health,t Bethesda, Maryland

Heart Rate Variability before and after the Endoscopic Transthoracic Sympathectomy in Hyperhidrosis

The etiology of primary hyperhidrosis has been speculated as "unknown" hyperactivity of the sympathetic nervous system. In our clinic, we performed endoscopic transthoracic sympathectomy(ETS) for the treatment of hyperhidrosis. In this study, we studied the cardiac autonomic nervous function using heart rate variability(HRV) before and after ETS in 70 patients with hyperhidrosis, and compared with normal control. Before ETS, high frequency(HF) power was lower in hyperhidrosis than control group, however, there was no significant difference in LF/HF. After ETS, LF/HF decreased by 31%, and lower than control. No Severe cpomplications were occurred by ETS. In conclusion, on the cardiac autonomic nervous tone, hyperhidrosis patients had the relative dominance of the sympathetic nervous tone by suppression of the parasympathetic nervous tone. After ETS, the sympathetic nervous tone was suppressed.

http://sciencelinks.jp/j-east/article/200002/000020000299A0930354.php

Heart Rate Variability before and after the Endoscopic Transthoracic Sympathectomy in Hyperhidrosis.
Accession number;99A0930354
Title;Heart Rate Variability before and after the Endoscopic Transthoracic Sympathectomy in Hyperhidrosis.
Author; YOSHIDA K (Saga Medical School) UTSUNOMIYA T (Saga Medical School) HIRATA M (Saga Medical School) MOROOKA T (Saga Medical School) MATSUO A (Saga Medical School) SHIRAHAMA K (Saga Medical School) TANAKA M (Saga Medical School) HARANO K (Saga Medical School) MATSUO S (Saga Medical School)
Journal Title;Ther Res
Journal Code:Y0681A
ISSN:0289-8020 VOL.20;NO.9;PAGE.2630-2634(1999) Figure&Table&Reference;FIG.2, REF.19 Pub. Country;Japan
Language;English 

HRV is a direct predictor of cardiovascular risk and all-cause mortality (TaskForce 1996)

Heart rate variability (HRV) is of increasing interest because it is a marker of cardiovascular autonomic function and because reduced HRV is a direct predictor of cardiovascular risk and all-cause mortality (TaskForce 1996). While they do not provide direct measures of autonomic activity, indices from HRV are widely recognized as useful and powerful indicators of the relationship between psychological and physiological processes (Berntson et al. 1997; Pagani et al. 1997; TaskForce 1996).



HRV can be evaluated by time and frequency domain indices, reflecting the activity of the autonomic nervous system. Among the most used indices, the standard deviation of normal beatto-beat (R–R) intervals

(SDNN) has been suggested to reflect global variability, while the root-mean-square of successive R–R (RMSSD) and high frequency (HF) power have been linked to vagal activity (TaskForce 1996). Although more controversial, low frequency (LF) power is thought to reflect sympathetic activity with a parasympathetic component (Berntson et al.1997; Pomeranz et al. 1985; but see Pagani et al. 1997).

http://cerca.labo.univ-poitiers.fr/IMG/pdf_EJAP10-AlbinetColl.pdf

important relationship among cognitive performance, HRV, and prefrontal neural function

Heart rate variability, prefrontal neural func... [Ann Behav Med. 2009] - PubMed - NCBI: "These findings in total suggest an important relationship among cognitive performance, HRV, and prefrontal neural function that has important implications for both physical and mental health. Future studies are needed to determine exactly which executive functions are associated with individual differences in HRV in a wider range of situations and populations."

http://www.ncbi.nlm.nih.gov/pubmed/19424767

Reduced HRV is significantly associated with lower cognitive performance

http://www.ncbi.nlm.nih.gov/pubmed/24077752

cardiovascular adjustment to exercise and sympathectomy

Mean arterial pressure and total peripheral resistance were significantly reduced at rest and during steady state of exercise as compared to controls prior to sympathectomy identical vO₂, whereas CO remained unchanged.

The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.

http://www.springerlink.com/content/k2n6j4555g16x773/

Sympathectomy altered electroactivity on the heart

The influences on the cardiac autonomic nerve system of the ETS of upper thoracic sympathetic nerve were seen to be of a lesser degree at rest. However, the response to sympathetic stimulation was suppressed after the surgery.

Eur J Cardiothorac Surg 1999;15:194-198

http://ejcts.ctsnetjournals.org/cgi/content/full/15/2/194

dennervation sensitization increases the arrhythmia susceptibility

The NA content in the heart was not measured but it is likely to be small at least at the 10-day period. It is known that three days after chemical sympathectomy NA content is only 7% of normal value [6]. Second, the development of adrenoceptor supersensitivity in the transplanted heart was demonstrated clearly with enhanced heart rate responses to NA or propranolol (at Day 10) [1]. As dennervation sensitization increases the arrhythmia susceptibility [6], it is thus possible that, in the presence of receptor supersensitivity, adrenergic activation occurs by either increase in circulating catecholamines and possibly local release of residual NA, which might still have been sufficient to contribute to arrhythmia development.
Role of sympathoadrenergic mechanisms in arrhythmogenesis
Xiao-Jun Du* and Anthony M. Dart
Baker Medical Research Institute, Melbourne, Victoria, Australia 
Cardiovascular Research 1999 43(4):832-834;

A 54-year-old woman developed possible heart failure while receiving pregabalin for intercostal neuralgia after sympathectomy

Anonymous. Reactions Weekly 1392 (Mar 10, 2012): 39.

A 54-year-old woman developed possible heart failure while receiving pregabalin [route not stated] for intercostal neuralgia.

The woman, who had a history of bilateral thoracic sympathectomy, started treatment with pregabalin 150 mg/day for the first week, followed by 300 mg/day in the second week. Tramadol was also administered. During follow-up on day 17 of treatment, she reported a 3-day history of swelling in her hands and ankles. Pretibial oedema was evident on examination and she was admitted for side-effect follow-up and pain palliation. 

During follow-up, a thorax CT scan revealed cardiomegalia, the presence of pericardial fluid, and pleural fluid at the base of both hemithorax, more significantly on the right side.

Diuretic therapy was initiated and, on day 3 of treatment, echocardiography showed an ejection fraction of 76%. A follow-up thorax CT scan, performed 15 days after discontinuing pregabalin, revealed disappearance of the cardiomegalia and pericardial fluid, with only minimal pleural effusion. The woman's peripheral oedema and dyspnoea had also subsided. Following reports of reduced but persistent pain, gabapentin 300 mg/day was initiated, followed by a dosage increase to 900 mg/day. 

References

1. Erdogan G, Ceyhan D, Gulec S.Possible heart failure associated with pregabalin use: case report. Agri 23: 80-3, No. 2, Apr 2011 - Turkey.

Thoracoscopic sympathectomy increases efferent cardiac vagal activity and baroreceptor sensitivity

Thoracoscopic sympathectomy at levels T2 or T2-T3 is a treatment for focal hyperhidrosis and facial blushing. These levels of the sympathetic trunk innervate the heart, and consequently, the procedure is reported to change the heart rate variability due to changes in efferent cardiac autonomic activity. Our objective was to investigate the effects of thoracoscopic sympathectomy on global autonomic control, including baroreceptor sensitivity.

Eight patients (6 F, median age 28 years [range 20-58 years]) were exposed to the tilt-table test and cardiopulmonary exercise test before, and 3 months after, thoracoscopic sympathectomy. Eight healthy age-, gender- and BMI-matched controls were used as controls and underwent the same tests once. During tilt-table testing electrocardiogram, blood pressure, impedance cardiography and respiration were measured continuously, and efferent cardiac autonomic balance was estimated.

RESULTS:

The heart rate measured during orthostatic stress test was lowered after thoracoscopic sympathectomy (between-group; P = 0.01) due to a change in autonomic tone, with increased vagal (high-frequency power n.u.; P = 0.001), and reduced sympathetic efferent cardiac activity (low-frequency power n.u.; P < 0.001). Baroreceptor sensitivity measured during rest was increased (26 ± 13 vs 44 ± 19 ms/mmHg; P = 0.01), and diastolic blood pressure reduced after surgery (P = 0.01).

http://www.ncbi.nlm.nih.gov/pubmed/23847183

SYMPATHECTOMY FOR ANGINA

Hirakawa, Naomi; Ogawa, Ikuyo; Yoshida, Kazuyo; Totoki, Tadahide

Institution
Anesthesiology and Critical Care Medicine, Cardiology, Saga Medical School, Saga, Saga, Japan.
Title
Effects of Endoscopic Thoracic Sympathectomy (ETS) for the Treatment of Patients with Intractable Vasospastic Angina. #151; Changes in Autonomic Nervous Activity and Symptomatic Change after ETS in Patients with Intractable Vasospastic Angina #151;.[Miscellaneous]
Source
ASA Annual Meeting Abstracts. LOCAL ANESTHESIA AND PAIN. 99(3A):A998, October 2003.

very little is known concerning its direct vascular or indirect metabolic effects that will explain its success in some cases and its failure in others

Annals of Internal Medicine | THE HEMODYNAMIC EFFECTS OF SYMPATHECTOMY IN ESSENTIAL HYPERTENSION*: "Surgical sympathectomy has been employed so extensively for the treatment of essential hypertension that one might assume its hemodynamic effects to be completely understood. Quite to the contrary, however, very little is known concerning its direct vascular or indirect metabolic effects that will explain its success in some cases and its failure in others. Until these matters are fully understood the rationale for surgical treatment, and indeed for medical management, of essential hypertension must remain on an empirical basis. For this reason these problems have been and will continue to be the subject of long-term investigation in this laboratory."



'via Blog this'

the autonomic nervous system varies in a unique, autonomous manner, and it is therefore difficult to assess changes in patients in a uniform manner

There are several reasons that stellate ganglion block affects the cardiovascular system. Stellate ganglion block will initially affect both the sympathetic and parasympathetic nervous systems based on the degree of block. The intensity of right stellate ganglion blockage of the sympathetic and parasympathetic nervous system will result in heart rate changes and altered activity of the sympathetic and parasympathetic nervous system. Efferent sympathetic innervation from the right stellate ganglion is primarily distributed over the sinus node of the heart, and the influence of the autonomic nervous system and left stellate ganglion block should be assessed. Further, results will be affected by the health status of participants.

Although efferent sympathetic nerves from the stellate ganglion are primarily distributed over the heart, efferent sympathetic fibers from the 2nd to 5th thoracic ganglia affect the heart as well. Accordingly, the autonomic nervous system of the heart is not completely dependent on the stellate ganglia. The influence of the autonomic nervous system cannot be excluded as well. It is worth noting that the mepivacaine in the present study was a lower dosage than those used in other studies. Finally, the autonomic nervous system varies in a unique, autonomous manner, and it is therefore difficult to assess changes in patients in a uniform manner or just through the application of one or two indicators. Future studies should examine diverse methods for the assessment of autonomic nervous system function.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2872892/

R-R variations, a test of autonomic dysfunction

Patients with symptoms of autonomic failure showed smaller variations than those without such symptoms.

Acta Neurologica Scandinavica

http://www3.interscience.wiley.com/journal/121523081/abstract?CRETRY=1&SRETRY=0

sympathectomy contributing to the elevated susceptibility to ventricular fibrillation

We conclude that chemical sympathectomy downregulates the expression of selective Kv channel subunits and decreases myocardial I_to channel activities, contributing to the elevated susceptibility to ventricular fibrillation.
Can. J. Physiol. Pharmacol. 86(10): 700–709 (2008)

The sympathetic system is responsible for the physiological responses to emotional states

The common epithet of “fight or flight” is being enlarged to be “fight, flight, or fright” or even “fight, flight, fright, or freeze.” Cannon’s original contribution was a catchy phrase to express some of what the nervous system does in response to a threat, but it is incomplete. The sympathetic system is responsible for the physiological responses to emotional states. The name “sympathetic” can be said to mean that (sym- = “together”; -pathos = “pain,” “suffering,” or “emotion”).
http://cnx.org/content/m46582/latest/?collection=col11496/latest

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.pdfby W RAAB - 1960

histochemical comparison of the normal and chronically sympathectomized heart

Jones CE, Cannon MS.

Using histochemical techniques, the reactivities of selected enzymes and other metabolic components were examined in the myocardium, coronary arteries, and coronary arterioles of normal, two-week-sympathectomized, and sham-operated canine hearts. There were no differences in the histochemistry of coronary arteries in any of the hearts, but important differences were noted in the myocardium and especially in the arterioles. The reactivities of the enzyme glucose-6-phosphate dehydrogenase and the nucleic acids were increased in arterioles of the sympathectomized heart, possibly indicating an increased protein synthesis. The reactivities of succinate dehydrogenase, NAD-isocitrate dehydrogenase, and cytochrome oxidase were reduced in myocardium and arterioles of sympathectomized hearts as well as in arterioles of sham-operated hearts; the changes were greater in the sympathectomized arterioles where there was also observed an increase in reactivity of lactate dehydrogenase. These findings suggest a depression in aerobic metabolic capacity and, in the case of the sympathectomized arteriole, imply a possible shift in adaptation from aerobic to anaerobic metabolism.
Histochem J. 1980 Jan;12(1):9-22.

change in sympathetic nervous system activity after thoracic sympathectomy

The photoplethysmographic (PPG) signal, which measures cardiac-induced changes in tissue blood volume by light transmission measurements, shows spontaneous fluctuations. In this study, PPG was simultaneously measured in the right and left index fingers of 16 patients undergoing thoracic sympathectomy, and, from each PPG pulse, the amplitude of the pulse (AM) and its maximum (BL) were determined. 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.

Medical and Biological Engineering and Computing

2001, Volume 39, Issue 5, pp 579-583
http://link.springer.com/article/10.1007%2FBF02345149