Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation

Fabrizio R. Assis, Diana H. Yu, Xun Zhou, Sunjeet Sidhu, Anisha Bapna, Zoar J. Engelman, Satish Misra, David R. Okada, Jonathan Chrispin, Ronald D Berger, Kaushik Mandal, Hans J Lee, Harikrishna Tandri

Research output: Contribution to journalArticle

Abstract

Background: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. Objective: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. Methods: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. Results: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dTmax (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. Conclusion: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery.

Original languageEnglish (US)
JournalHeart Rhythm
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Lidocaine
Stellate Ganglion
Injections
Swine
Sympathectomy
Denervation
Trachea
Sodium Chloride
Arterial Pressure
Hemodynamics
Morbidity
Lung

Keywords

  • Aortopulmonary window
  • Cardiac plexus
  • Denervation
  • Endobronchial ultrasound
  • Neuromodulation
  • Refractory arrhythmia
  • Stellate ganglia
  • Sympathectomy
  • Transtracheal
  • Ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation. / Assis, Fabrizio R.; Yu, Diana H.; Zhou, Xun; Sidhu, Sunjeet; Bapna, Anisha; Engelman, Zoar J.; Misra, Satish; Okada, David R.; Chrispin, Jonathan; Berger, Ronald D; Mandal, Kaushik; Lee, Hans J; Tandri, Harikrishna.

In: Heart Rhythm, 01.01.2018.

Research output: Contribution to journalArticle

Assis, Fabrizio R. ; Yu, Diana H. ; Zhou, Xun ; Sidhu, Sunjeet ; Bapna, Anisha ; Engelman, Zoar J. ; Misra, Satish ; Okada, David R. ; Chrispin, Jonathan ; Berger, Ronald D ; Mandal, Kaushik ; Lee, Hans J ; Tandri, Harikrishna. / Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation. In: Heart Rhythm. 2018.
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title = "Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation",
abstract = "Background: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. Objective: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. Methods: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1{\%} lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. Results: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes ({\%}) in T-wave amplitude (282.8{\%} ± 152.2{\%} vs 20.1{\%} ± 16.5{\%}; P <.001 [LSG]; 338.9{\%} ± 189.8{\%} vs 28{\%} ± 18.3{\%}; P <.001 [RSG]), Tp-Te interval (87.9{\%} ± 37.2{\%} vs 6.9{\%} ± 6.7{\%}; P <.001 [LSG]; 32.6{\%} ± 27.4{\%} vs 6.9{\%} ± 4.7{\%}; P <.035 [RSG]), and left ventricular dP/dTmax (148.3{\%} ± 108.5{\%} vs 16.5{\%} ± 13.4{\%}; P <.001 [LSG]; 243.1{\%} ± 105.2{\%} vs 19.0{\%} ± 12.4{\%}; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. Conclusion: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery.",
keywords = "Aortopulmonary window, Cardiac plexus, Denervation, Endobronchial ultrasound, Neuromodulation, Refractory arrhythmia, Stellate ganglia, Sympathectomy, Transtracheal, Ventricular tachycardia",
author = "Assis, {Fabrizio R.} and Yu, {Diana H.} and Xun Zhou and Sunjeet Sidhu and Anisha Bapna and Engelman, {Zoar J.} and Satish Misra and Okada, {David R.} and Jonathan Chrispin and Berger, {Ronald D} and Kaushik Mandal and Lee, {Hans J} and Harikrishna Tandri",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.hrthm.2018.07.037",
language = "English (US)",
journal = "Heart Rhythm",
issn = "1547-5271",
publisher = "Elsevier",

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TY - JOUR

T1 - Minimally invasive transtracheal cardiac plexus block for sympathetic neuromodulation

AU - Assis, Fabrizio R.

AU - Yu, Diana H.

AU - Zhou, Xun

AU - Sidhu, Sunjeet

AU - Bapna, Anisha

AU - Engelman, Zoar J.

AU - Misra, Satish

AU - Okada, David R.

AU - Chrispin, Jonathan

AU - Berger, Ronald D

AU - Mandal, Kaushik

AU - Lee, Hans J

AU - Tandri, Harikrishna

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. Objective: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. Methods: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. Results: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dTmax (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. Conclusion: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery.

AB - Background: Bilateral thoracoscopic stellectomy has antiarrhythmic effects, but the procedure is invasive with associated morbidity. Sympathetic nerves from both stellate ganglia form the deep cardiac plexus (CP) in the aortopulmonary window, anterior to the trachea. Objective: The purpose of this study was to demonstrate a novel and minimally invasive transtracheal approach to block the CP in porcine models. Methods: In 12 Yorkshire pigs, right (RSG) and left (LSG) stellate ganglia were electrically stimulated and sympathetic baseline response recorded (hemodynamic parameters and T-wave pattern). Aortopulmonary window was accessed transtracheally with endobronchial ultrasound guidance, and local stimulation of CP confirmed the location. Injection of 1% lidocaine (n = 10) or saline solution (n = 2) was performed, and RSG and LSG responses were re-evaluated and compared with baseline. Results: Transtracheal lidocaine injection into the CP successfully blocked bilateral sympathetic induced changes (%) in T-wave amplitude (282.8% ± 152.2% vs 20.1% ± 16.5%; P <.001 [LSG]; 338.9% ± 189.8% vs 28% ± 18.3%; P <.001 [RSG]), Tp-Te interval (87.9% ± 37.2% vs 6.9% ± 6.7%; P <.001 [LSG]; 32.6% ± 27.4% vs 6.9% ± 4.7%; P <.035 [RSG]), and left ventricular dP/dTmax (148.3% ± 108.5% vs 16.5% ± 13.4%; P <.001 [LSG]; 243.1% ± 105.2% vs 19.0% ± 12.4%; P <.001 [RSG]). RSG-induced elevations of systemic, left ventricular, and pulmonary arterial pressures were blocked by lidocaine injection into CP (P <.005 for all comparisons). Stellate ganglia response was not affected in sham studies. No complications were observed during the procedures. Conclusion: Minimally invasive transtracheal injection of lidocaine into the CP blocked the sympathetic response of either RSG and LSG. Transtracheal assessment of CP may allow for minimally invasive and selective ablation of cardiac innervation, extending the cardiac sympathectomy denervation benefits to those not suitable for surgery.

KW - Aortopulmonary window

KW - Cardiac plexus

KW - Denervation

KW - Endobronchial ultrasound

KW - Neuromodulation

KW - Refractory arrhythmia

KW - Stellate ganglia

KW - Sympathectomy

KW - Transtracheal

KW - Ventricular tachycardia

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U2 - 10.1016/j.hrthm.2018.07.037

DO - 10.1016/j.hrthm.2018.07.037

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JO - Heart Rhythm

JF - Heart Rhythm

SN - 1547-5271

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