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PRESENTATION #1 Case Report | Cardiac Anesthesia

BILATERAL THORACIC SYMPATHECTOMY WITH VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS) IN A PATIENT WITH REFRACTORY ANGINA

Jimmie Colon, MD. Ochsner Medical Center

Presenter: Sahar Niazi, BS, MS
Ochsner Health System

Background: Video assisted thoracoscopic surgical sympathectomy has proven to be an effective procedure in the management of intractable angina pectoris that is unresponsive to medical management alone or in a patient who is not a suitable candidate for coronary artery revascularization [1]. The relationship between relief of anginal pain and sympathectomy is related to the physiologic connection of the central nervous system to the myocardium via the sympathetic autonomic nervous system; vasospasms leading to ischemia of the myocardium results in the release of activating substances, including bradykinin and adenosine, which stimulate afferent fibers of the sympathetic nervous system [2]. Pain signals are then carried to, primarily, the sympathetic ganglia at the level of T2 to T6 – resulting in the sensation of angina in the patient [2].

Case Report: We report the medical history, surgical procedure and post-operative findings in a 27-year old female who underwent video assisted thoracoscopic surgery (VATS) for bilateral thoracic sympathectomy for refractory Prinzmetal angina. The patient has a complex medical history of obesity, recurrent angina pectoris, coronary artery disease, AICD, systolic congestive heart failure, recurrent ventricular arrhythmias, hypertension, seizures, pulmonary embolism and a surgical history of thoracic epidurals and stellate ganglion blocks. The patient experienced two weeks of post-procedural relief of symptoms with total return of symptoms after this time period.

Conclusion: Though literature suggests a high degree of long-term symptomatic relief of angina pectoris symptoms in patients undergoing thoracic sympathectomy [3], individual patient results can vastly differ. Results of the procedure are further individualized in unexampled patient populations, such as our patient, who is below the age of thirty and has an extensive medical and surgical history.

REFERENCES:

1. Holland, L.C., Navaratnarajah, M., Taggart, D.P. (2016). Does surgical sympathectomy improve clinical outcomes in patients with refractory angina pectoris?, Interactive CardioVascular and Thoracic Surgery, Volume 22, Issue 4, April 2016, Pages 488–492, https://doi.org/10.1093/icvts/ivv386

2. Moore R., Groves D., Hammond C., Leach A., Chester M.R. Temporary sympathectomy in the treatment of chronic refractory angina. Journal of Pain and Symptom Management. (2005). Volume 30, Issue 2, August 2005. Pages 183-191, https://doi.org/10.1016/j.jpainsymman.2005.02.016

3. Rathinam, S., Nanjaiah, P., Sivalingam, S. Rajesh, P.B. (2008). Excision of sympathetic ganglia and the rami communicantes with histological confirmation offers better early and late outcomes in video assisted thoracoscopic sympathectomy. Journal of Cardiothoracic Surgery. Volume 50, Issue 3, August 2008. https://doi.org/10.1186/1749-8090-3-50