Role of Bilateral Sympathectomy in the Treatment of Refractory Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy.

Ventricular arrhythmias in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) are precipitated by an increase in sympathetic activity, typically physical exercise. As such, β blockade is the cornerstone of medical treatment. However, some patients are either intolerant or refractory to β-blockers, and many continue to have arrhythmias despite catheter ablation. This report presents the case of an ARVD/C patient with severe ventricular arrhythmias refractory to β-blockade, antiarrhythmic drugs, and 3 endocardial/epicardial ventricular tachycardia (VT) ablations, who was successfully treated with bilateral sympathectomy. A previously healthy 16-year-old male triathlete presented with a sudden cardiac arrest while swimming. He was diagnosed with ARVD/C based on T-wave inversions V1–V4, 7216 premature ventricular complexes on 24-hour Holter monitoring, left bundle inferior axis VT, and subtricuspid dyskinesia with right ventricular ejection fraction 33% (Figure 1). Genetic testing revealed no pathogenic mutation in a 76-gene cardiomyopathy panel (including all 5 desmosomal genes), and he had no familial history of disease. He received a single-chamber implantable cardioverter–defibrillator (ICD) and was discharged on sotalol. Five months after discharge, the patient received his first shock for VT at 233 beats per minute while dancing. He underwent an endocardial/epicardial VT ablation (Figure 2) and was noninducible at the end of the procedure during programmed stimulation with and without isoproterenolol. He was discharged on long-acting metoprolol. Flecainide was added when palpitations recurred soon after discharge. Five months later, he experienced a VT storm requiring 43 ICD shocks after climbing stairs. He received cardiopulmonary resuscitation and regained consciousness 2 days later. He underwent a second endocardial/epicardial ablation. A stress test …