Surgical thoracic sympathectomy can result in functional changes in the intrathoracic organs

Surgical thoracic sympathectomy such as ESD (endoscopic thoracic sympathectic denervation) or heart transplantation can result in an imbalance between the sympathetic and parasympathetic activities and result in functional changes in the intrathoracic organs. Therefore, the procedures affecting sympathetic nerve functions, such as epidural anesthesia, ESD, and heart transplantation, may cause an imbalance between sympathetic and parasympathetic activities (1, 6, 16, 17). Recently, it has been reported that ESD results in functional changes of the intrathoracic organs. In conclusion, our study demonstrated that ESD adversely affected lung function early after surgery and the BHR was affected by an imbalance of autonomic activity created by bilateral ESD in patients with primary focal hyperhidrosis. Journal of Asthma, 46:276–279, 2009 http://informahealthcare.com/doi/abs/10.1080/02770900802660949

patients that has been treated with ETS need to be observed during high-level exercise

CARDIOVASCULAR EFFECTS OF BILATERAL ENDOSCOPIC TRANSTHORACIC SYMPATHICOTOMY AT REST AND DURING EXERCISE IN PATIENTS WITH PALMAR HYPERHIDROSIS

AUTHORS: Kazushi Takaishi, MD, Etsuo Tabo, MD, Kazuo Nakanishi, MD, Masao Soutani, MD,PhD, Kyoji Tsuno, MD, Tatsuru Arai, MDAFFILIATION: Ehime University, Shigenobu, Japan.
INTRODUCTION: Palmar hyperhidrosis is characterized by an overactivity of the sympathetic fibers passing through T2 and T3 ganglia. Although endoscopic transthoracic sympathicotomy (ETS) is an effective treatment for palmar hyperhidrosis, the partial cardiac denervation that follows may cause impairment of cardiovascular function at rest and during exercise. The purpose of this study was to compare the cardiovascular response to exercise between patients with palmar hyperhidrosis and a normal control population, and to examine the effects of ETS on cardiovascular response in patients with palmar hyperhidrosis.
METHODS: After institutional approval and informed consent, 16 patients with palmar hyperhidrosis undergoing bilateral T2- T4 ETS and 10 healthy volunteers were studied. First, before ETS administration, heart rate (HR), blood pressure (BP), and serum catecholamine (SC) at rest were measured in the patient group and in normal subjects. Then, changes in HR, BP and SC as a result of isometric handgrip exercise (IHE) were measured in both groups. Finally, HR and BP at rest, changes in HR and BP as a result of general exercise (GE), and changes in HR, BP and SC as a result of IHE were measured in the patient group both one day before and one day after ETS was administered.RESULTS: Although there was no significant difference in HR and BP at rest between the patient group before ETS and normal subjects, the value of serum adrenaline in the patient group (0.6 ng/ml) was significantly lower than that in normal subjects (2.6 ng/ml, p<0.01). Changes in HR, BP and SC to IHE were similar in both groups before ETS. HR and BP at rest, and changes in HR and BP as a result of GE and IHE were significantly decreased after ETS (p<0.05).

DISCUSSION: 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.

K Takaishi, E Tabo, K Nakanishi, M Soutani, K Tsuno, T Arai:
Cardiovascular effects of bilateral endoscopic transthoracic sympathicotomy at rest and during exercise in patients with palmar hyperhidrosis.
International Anesthesia Research Society
The 74th Clinical and Scientific Congress 2000 

Snipping the nerve may stop 'flight-or-fight' stress response

What do sweaty palms and abnormal heart rhythms have in common? Both can be initiated by the nervous system during an adrenaline-driven "flight-or-fight" stress reaction, when the body senses danger.

Hyperhidrosis, an abnormal flight-or-fight response of the sympathetic nervous system that causes excessively sweaty palms may also contribute to problems like dangerous irregular rhythms from the lower chambers of the heart, known as ventricular arrhythmias.

UCLA cardiologists have now found that surgery to snip nerves associated with the sympathetic nervous system on both the left and right sides of the chest may be helpful in stopping dangerous, incessant ventricular arrhythmias — known as an "electrical storm" — when other treatment methods have failed. This same type of surgery has been used for years to alleviate hyperhidrosis.

The UCLA team's findings are reported in the Dec. 27–Jan. 3 issue of the Journal of the American College of Cardiology. The study is one of the first to assess the impact of bilateral cardiac sympathetic denervation (BCSD), surgery on both sides of the heart, to control arrhythmias. The research builds on previous work at UCLA in which a similar procedure was performed only on the left side. But for some patients to obtain relief, the researchers said, it must be done bilaterally. 

http://newsroom.ucla.edu/releases/snipping-key-nerves-may-help-life-220281 

Sympathectomy - a neurocardiologic disorder

Bilateral thoracic sympathectomies or sympathotomies are done for refractory palmar hyperhidrosis [85–87]. Iontophoresis, botulinum toxin injection, and glycopyrrolate cream are alternatives. Because sweating is mediated mainly by sympathetic cholinergic fibers, autonomic neurosurgery is usually effective; however, a variety of expected and unexpected consequences can result, including ectopic (e.g., plantar) hyperhidrosis, gustatory sweating, Horner syndrome, and decreased heart rate responses to exercise. The latter seems to be related to partial cardiac denervation [88]. Anecdotally, fatigue, altered mood, blunted emotion, and decreased ability to concentrate can develop after bilateral thoracic sympathectomies. 

β-Adrenoceptor blockers are a mainstay of treatment for CPVT. An automated defibrillator may have to be implanted. Treatment for CPVT also includes left sympathectomy. Such treatment leaves open the theoretical possibilities of denervation supersensitivity of cardiac adrenoceptors and compensatory activation of the adrenomedullary hormonal system; however, plasma levels of catecholamines have not been assessed in CPVT with or without therapeutic cardiac denervation.

Table 1. Neurocardiologic disorders that feature abnormal catecholaminergic function

Disorders where abnormal catecholaminergic function is etiologic Hypofunctional states without central neurodegeneration
Acute, primary
Neurocardiogenic syncope Spinal cord transection Acute pandysautonomia Sympathectomy
Acute, secondary
Drug-related (e.g., alcohol, tricyclic antidepressant, chemotherapy, opiate, barbiturates, benzodiazepines, sympatholytics, general anesthesia)
Seizures
Guillain–Barre syndrome Alcohol

Chronic, primary

Pure autonomic failure
Horner's syndrome
Familial dysautonomia
Carotid sinus syncope

Adie's syndrome Dopamine-β-hydroxylase deficiency
Sympathectomy 

http://onlinelibrary.wiley.com/doi/10.1111/j.1755-5922.2010.00244.x/full

https://archive.is/UMW1w

Patients may develop bradycardia after surgical procedure to treat sweaty hands and blushing

Upper-Thoracic Sympathectomy; Patients may develop bradycardia after surgical procedure

Heart Disease Weekly. Atlanta: Feb 23, 2003. pg. 71

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

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

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side

European Journal of Cardio-Thoracic Surgery > 2001 > 20 > 6 > 1095-1100

chronic interference with β-adrenergic receptors (via either sympathectomy or β-blockade) on cardiac mast cell morphology/activation and on interstitial collagen deposition

In the present study we investigated the effects of chronic interference with β-adrenergic receptors (via either sympathectomy or β-blockade) on cardiac mast cell morphology/activation and on interstitial collagen deposition. In rats subjected to chemical sympathectomizy with the neuro- toxin 6-hydroxydopamine (6-OHDA) we observed a significant increase of mast cell density, and in particular of degranulat- ing mast cells, suggesting a close relationship between the cardiac catecholaminergicsystem and mast cell activation. In parallel, chronic 6-OHDA treatment was associated with increased collagen deposition. The influence of the β-adren- ergic receptor component was investigated in rats subjected to chronic propranolol administration, that caused a further significant increase in mast cell activation associated with a lower extent of collagen deposition when compared to chem- ical sympathectomy. These data are the first demonstration of a close relationship between rat cardiac mast cell activation and the catecholaminergic system, with a complex interplay with cardiac collagen deposition. Specifically, abrogation of the cardiac sympathetic efferent drive by chemical sympathectomy causes mast cell activation and interstitial fibrosis, possibly due to the local effects of the neurotoxin 6-hydroxy- dopamine. In contrast, β-adrenergic blockade is associated with enhanced mast cell degranulation and a lower extent of collagen deposition in the normal myocardium. In conclusion, cardiac mast cell activation is influenced by β-adrenergic influences. 

http://www.ejh.it/index.php/ejh/article/viewFile/985/1108

Correspondence: Rosanna Nano,

Department of Animal Biology, University of Pavia,

European Journal of Histochemistry

2006; vol. 50 issue 2 (Apr-Jun):133-140

Chronic bradycardia can cause fatigue, shortness of breath on exertion and dizziness

Bradycardia is defined as a heart rate below 60 beats per minute. However, slow heart rates are often found in normal people, especially at rest or if very fit. Sinus bradycardia, junctional escape rhythm and Wenckebach block can also be seen in normal people and are usually asymptomatic.

Patients with asymptomatic bradycardia usually need no treatment.

Intermittent severe bradycardia can cause syncope. Chronic bradycardia can cause fatigue, shortness of breath on exertion and dizziness. Severe bradycardia can cause haemodynamic consequences of hypotension, altered conscious state, poor perfusion, ischaemic chest pain and cardiac failure. However, in the presence of bradycardia and haemodynamic compromise it is important to look for other factors such as myocardial infarction or poor ventricular function.

Patients with syncope, other symptoms or haemodynamic compromise due to bradycardia should be referred urgently for consideration of pacemaker implantation.

Transcutaneous pacing may be required in the emergency setting for acute severe bradycardia causing severe haemodynamic compromise. Temporary transvenous pacing may be required in patients with acute, symptomatic bradycardia. Patients with chronic symptomatic bradycardia and some patients with asymptomatic but significant bradyarrhythmias require permanent pacemaker implantation.

Revised February 2012. ©Therapeutic Guidelines Ltd (etg43demo November 2014) 

http://www.tg.org.au/etg_demo/desktop/tgc/cvg6/2878.htm 

regional myocardial denervation creates autonomic and electrophysiological heterogeneity and the substrate for heterogeneous drug actions

These data show that regional myocardial denervation creates autonomic and electrophysiological heterogeneity and the substrate for heterogeneous drug actions. This drug-induced electrophysiological heterogeneity may be another mechanism for proarrhythmia. 

Circulation. 1991 Oct;;84(4):1709-14.
Modulation of drug effects by regional sympathetic denervation and supersensitivity.
Stanton MS, Zipes DP.
Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis 46202. 

chronic interference with β-adrenergic receptors (via either sympathectomy or β-blockade) on cardiac mast cell morphology/activation and on interstitial collagen deposition

In the present study we investigated the effects of chronic interference with β-adrenergic receptors (via either sympathectomy or β-blockade) on cardiac mast cell morphology/activation and on interstitial collagen deposition. In rats subjected to chemical sympathectomizy with the neuro- toxin 6-hydroxydopamine (6-OHDA) we observed a significant increase of mast cell density, and in particular of degranulat- ing mast cells, suggesting a close relationship between the cardiac catecholaminergic system and mast cell activation. In parallel, chronic 6-OHDA treatment was associated with increased collagen deposition. The influence of the β-adren- ergic receptor component was investigated in rats subjected to chronic propranolol administration, that caused a further significant increase in mast cell activation associated with a lower extent of collagen deposition when compared to chem- ical sympathectomy. These data are the first demonstration of a close relationship between rat cardiac mast cell activation and the catecholaminergic system, with a complex interplay with cardiac collagen deposition. Specifically, abrogation of the cardiac sympathetic efferent drive by chemical sympathectomy causes mast cell activation and interstitial fibrosis, possibly due to the local effects of the neurotoxin 6-hydroxy- dopamine. In contrast, β-adrenergic blockade is associated with enhanced mast cell degranulation and a lower extent of collagen deposition in the normal myocardium. In conclusion, cardiac mast cell activation is influenced by β-adrenergic influences. 

http://www.ejh.it/index.php/ejh/article/viewFile/985/1108

Correspondence: Rosanna Nano,
Department of Animal Biology, University of Pavia,

European Journal of Histochemistry

2006; vol. 50 issue 2 (Apr-Jun):133-140

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."