Eur J Cardiothorac Surg 1999;16:S95-S98
© 1999 Elsevier Science NL
Video-assisted thoracoscopic sympathectomy for severe intractable angina
S.S. Khogali*,
M. Miller,
P.B. Rajesh,
R.G. Murray,
J.M. Beattie
Departments of Cardiology and Thoracic Surgery, Heartlands Hospital, Birmingham, UK
* Corresponding author. University Department of Cardiovascular Medicine, Level 5, John Radcliffe Hospital Headington, Oxford 0X3 9DU, UK (Email: saib.khogali{at}paediatncs.ox.ac.uk).
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Abstract
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Objective: Endoscopic trans-thoracic sympathectomy is a well documented, safe and successful treatment for palmar and axillary hyperhidrosis. This may also be helpful in the management of patients with intractable angina and advanced coronary disease unsuitable for coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA). We evaluated video assisted thoracoscopic sympathectomy (VATS) in such patients with the aim of improving symptoms and quality of life. Methods: Video assisted thoracoscopic sympathectomy, a minimally invasive procedure, was performed under general anaesthesia with alternating single lung ventilation. Three stab incisions were made at the level of the fourth intercostal space in the anterior and posterior axillary lines, and at the fifth intercostal space in the mid-axillary line through which an extensive thoracic sympathectomy was performed to include second to the fourth ganglia, bilaterally. Results: A total of 16 patients aged 46–76 (mean 61) years were assessed for VATS. Of these 10 patients had the procedure performed; nine with previous CABG and one with diffuse coronary disease. Six patients were excluded because of an evolving MI (n=1), left ventricular ejection fraction (LVEF)<30% (n=2), and chronic stable angina with no objective evidence of ischaemia (n=3). All 10 patients had marked symptomatic improvement with reduction of both angina frequency and intensity of attacks. Mean follow-up period 11.5 months. Exercise tolerance and time to onset of angina measured on exercise treadmill was significantly increased post-VATS (P=0.028) and maintained 1 year post-operative. Conclusion: VATS was associated with both reduction in angina symptoms and an increase in exercise time to onset of angina. An improved quality of life was evident.
Key Words: Video assisted thoracoscopic sympathectomy • Angina • Trans-thoracic sympathectomy
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1. Introduction
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Endoscopic transthoracic electrocautery of the sympathetic chain [1] is a well documented safe and successful treatment for palmar and axillary hyperhidrosis which may be helpful in the treatment of patients with severe intractable angina. This procedure of sympathetic cardiac denervation first suggested by Francois-Frank in 1899 [2] was first adopted by Jonnesco in the 1920s [3], when a 38 year old choir singer with syphilitic aortitis had complete relief from angina for 4 years, following the operation. Subsequently, several investigators experienced variable and unpredictable results culminating in abandonment of the procedure. The first thoracoscopic excisions of ganglia were performed in the 1940s, however, the procedure did not gain popularity until the 1980s.
The management of patients with angina and coronary artery disease not suitable for conventional coronary revascularization is increasingly realised by cardiologists as a serious and escalating problem. These patients vary between those with intractable angina and diffuse end-vessel coronary artery disease unsuitable for angioplasty or coronary artery bypass grafts (CABG), history of previous coronary artery bypass grafting not suitable for PTCA or re-do surgery and those in whom co-morbidity precludes conventional intervention. The patients have a poor quality of life and have little option but to live with the chronic pain and disability. Evolving therapeutic approaches have included: long term intermittent urokinase, spinal cord stimulation and transmyocardial revascularization (TMR) [4]. All these are said to have anti-ischaemic properties but have yet to be validated in further studies of efficacy and cost-effectiveness. Over the past 2 years we have evaluated the use of video assisted thoracoscopic sympathectomy (VATS) for intractable angina as a therapeutic option with the primary aim of achieving symptomatic relief with an increase in functional capacity and consequently improved quality of life.
The anti-angina effects of the procedure are probably due to the combination of a direct anaesthetic effect of proximal sympathectomy, a reduction in myocardial oxygen demand due to alteration in the double product of heart rate and systolic blood pressure, and improvement in myocardial blood flow due to abolition of adrenoreceptor mediated coronary vasoconstriction. We report on our cohort of 10 patients who underwent VATS for intractable angina.
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2. Study design
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Over a 24 month period a total of 16 patients with intractable angina aged 46–76 (mean 61) years were assessed for VATS. The patients were referred with intractable angina despite maximal antianginal therapy. Of these, 10 patients had VATS performed; nine with previous CABG and one with diffuse coronary disease. The six patients excluded comprised an evolving MI (n=1), LVEF<30% (n=2), and chronic stable angina with no objective evidence of ischaemia (n=3). Initial assessment included a detailed history including anginal symptoms, degree of disability and effect of limitation on quality of life. Patients had a pre-study exercise tolerance test (ETT) (Bruce protocol) to assess exercise capacity and establish objective evidence of ischaemia. MUGA scan or transthoracic echocardiography (TTE) was performed to determine left ventricular function and those with an estimated LVEF<30% were excluded. All patients with stable refractory angina were assessed by angiography and the pattern of CAD documented. Those with progressive symptoms were re-assessed with coronary angiograms. Following angiography each patient's angiogram was peer group reviewed by an independent cardiologist and cardiothoracic surgeon whom agreed that conventional surgical approach was inappropriate. None of the patients were suitable for PTCA. One patient had been previously randomised to the placebo arm of a TMR study at another institution.
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3. Methods
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Video assisted thoracoscopic sympathectomy, a minimally invasive procedure, was performed under general anaesthesia with alternating single lung ventilation starting with the patient in the right lateral position with right lung ventilation and left sympathectomy to avoid arrhythmias [5]. Three stab incisions were made at the level of the fourth intercostal space in the anterior and posterior axillary lines, and at the fifth intercostal space in the mid-axillary line. An extensive thoracic sympathectomy was performed via these ports using diathermy and excision of thoracic sympathetic chain from the second to the fourth ganglia, bilaterally. The stellate ganglion was easily identified by its anatomic relations and left intact. The excised ganglia were confirmed histologically in each case. Each patient underwent Swan–Ganz catheterisation for peri-operative haemodynamic monitoring. ECG, ETT, Holter monitoring and LVEF estimation were performed pre- and post-VATS in each patient. There was no change to the anti-anginal medication. On discharge from the hospital each patient was given an angina diary to record severity of angina attacks, frequency and use of GTN spray. The patients were reviewed at 2 weeks then at 1, 3, 6 and 12 months.
The angina diary was reviewed and an ETT was performed between 1–6 months post-operatively. The time to onset of angina was compared to the pre-operative ETT. A TTE or MUGA scan was used to assess any change in LV function at 1/12 and 12 months post-operative. An SF36 quality of life questionnaire was recorded at pre-study assessment and 6 months after VATS.
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4. Results
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Following VATS all 10 patients had symptomatic improvement. The mean follow up period was 11.5 months. One of the 10 patients was 2 weeks post-VATS. There was no operative or post-operative mortality. One patient developed reflex hyperhidrosis and a transient Homer's syndrome, recognised complications of VATS. Each patient assumed an angina score of 10/10 pre-operative and scored the severity of attacks post-operative, out of 10 as well as recording the frequency of attacks in their angina diary.
Table 1
demonstrates the anginal score [6] using the Canadian Cardiovascular Society Classification (CCSC) [7] and each patient's subjective angina score out of 10 pre- and post-VATS. There was an unequivocal reduction in both the subjective severity of angina and the CCSC angina score in all the patients. However, the two patients who underwent unilateral VATS had a less marked reduction in the severity of angina. The frequency of angina episodes was markedly reduced in the 10 patients. The SF36 questionnaire administered before and after operation to nine patients demonstrated increased functional capacity consistent with improvement in quality of life.
Objectively, comparison of exercise time to onset of angina on a treadmill before and after VATS in six patients, 12–24 months following surgery is illustrated in Table 2
and Fig. 1. The exercise time to onset of angina was significantly increased post VATS in all six patients. Analysis of the difference between exercise duration pre- and post-VATS was performed using the Mann–Whitney non-parametric (Wilcoxon) test. There was a statistically significant increase in exercise time to angina post-VATS (P=0.028). Left ventricular function and LVEF estimate was unchanged on repeat echocardiography post-operatively.
In the early post operative period haemodynamic monitoring by Swan–Ganz catheterisation revealed no significant effects on cardiac index, pulmonary wedge pressure or left ventricular stroke work index. No arrhythmias were detected on 24 h ambulatory monitoring post-VATS.
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5. Discussion
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The difficulty of managing patients with intractable angina who are not suitable for conventional revascularization by CABG or PTCA is an increasingly prevalent problem. Coronary artery bypass patients are living longer and beyond their vein graft life expectancy. They develop angina due to graft blockage or disease and their native distal vessels will often demonstrate a significantly diseased ungraftable distal vessel. Angioplasty is often not an option. New approaches to managing intractable angina including intermittent urokinase, TMR and neurostimulation are currently under evaluation. There are disadvantages to each, the discussion of which is beyond the scope of this report. However, if the efficacy of each approach is found to be comparable, the evaluation of the practicability, accessibility to centres performing the procedure and cost-effectiveness is critical to judging the therapeutic strategy.
Although VATS is not a new procedure it is a novel albeit revisited approach in the management of intractable angina. The earlier attempts of open sympathectomies fell out of favour due to the variable inconsistent results. With recent advances in laparoscopic surgical techniques Wettervik et al. [8] demonstrated encouraging results in a small series in which they performed sympathectomy from TI–T5.
We performed VATS in a highly selected group who angiographically had no options for conventional revascularization. Sympathectomy was performed from T2 to T4 with the left sympathectomy always being performed first to avoid arrhythmogenicity [9,10]. We have demonstrated both subjective and objective improvement in symptoms and exercise capacity, respectively, with no alteration to the pre-operative medication. Importantly, none of the patients lost there warning signal of angina. They had an altered sensation of an impending attack which prompted the use of GTN spray.
Exercise time to onset of angina increased significantly post VATS (P=0.028). Functional capacity was therefore increased with improvement in quality of life as assessed by SF36 questionnaire. The Seattle angina questionnaire (SAQ), has more recently been accepted as a more disease-specific measure of CAD in which changes in the scores can detect important and subtle clinical changes. The SAQ should now replace the SF36 as a measure of quality of life in the context of CAD patient outcomes.
The series we have reported has demonstrated that VATS in intractable angina is a safe and effective therapeutic option, with good subjective and objective evidence. Important questions regarding the mechanisms and potential benefits of VATS remain unanswered. Is there improved oxygen delivery due to improved coronary flow? Have we by reducing/abolishing adrenoceptor mediated coronary vasoconstriction and improving coronary flow, significantly altered the oxygen supply demand ratio? This approach may have a survival benefit effect in addition to a therapeutic role in coronary disease.
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6. Conclusion
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Video assisted thoracoscopic sympathectomy in intractable angina improves both exercise capacity and quality of life in selected patients. Larger studies are required to further validate these results and answer the outstanding questions.
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Appendix
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Invited commentary
This is an interesting study. The concept of sympathectomy for the treatment of chronic intractable angina went out of favor for a variety of reasons. In part this was because it was overshadowed by the development of coronary artery bypass grafting and subsequently coronary angioplasty. Clearly, as this study shows, it is possible to do trans-thoracic sympathectomy with a minimally invasive technique and this is obviously a significant advantage for the patient However, just because we can now do the procedure in an easier way it does not necessarily mean that the technique is any better than it used to be. There is a significant group of patients (increasing in number) who suffer from intractable angina that are not suitable for further revascularization by bypass grafting or angioplasty Many of these patients are a problem for cardiologists and some are referred to pain clinics. In some there is a psychological overlay but many are getting ischemia and pain although the area may actually be small. There are alternative therapies which should also be considered such as laser transmyocardial revascularization and spinal cord stimulation. Both of these have been shown to produce symptomatic improvement. Spinal cord stimulation was compared to coronary bypass grafting in a randomized trial and shown to produce an equal degree of symptomatic benefit. Sympathectomy remains to be further evaluated in comparison to these other techniques. There are still many questions regarding the mechanisms as well as effectiveness. For instance what were the heart rate changes post sympathectomy and in particular what were the heart rate changes during exercise? Is there any evidence that myocardial perfusion is altered at all or is the technique just producing pain relief? This is an important question as we know that patients after heart transplantation who have an effective sympathectomy do not experience angina pain but they do get ischemia and even myocardial infarctions. It is surprising perhaps that in this group of patients they were able to feel angina and this therefore questions how complete the sympathectomy is. The ability to do a sympathectomy in a relatively non-invasive manner means that this technique now should be re-evaluated as a possible procedure for those patients with intractable angina who are unsuitable for revascularization. But many questions remain and a proper randomized trial needs to be done.John E. Sanderson,Department of Medicine and TherapeuticsDivision of CardiologyThe Chinese University of Hong KongPrince of Wales HospitalShatin, N.T. Hong Kong SAR.
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Footnotes
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong , November 20–21, 1998.
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References
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Top
Abstract
1. Introduction
