Cardiac-neuromodulation: Neural based clinical approaches for management of lifethreatening arrhythmias

      The autonomic nervous system plays a significant role in the genesis and maintenance of ventricular arrhythmias, modulating the underlying substrate in a dynamic manner. Multiple studies employing systemic and local modulation of the nervous system whether through medications or neuraxial modulation have been associated with a reduction in the risk of sudden cardiac death and burden of ventricular arrhythmias. Initially, cardiac neural anatomy and neural remodeling in the setting of scar and cardiomyopathy will be reviewed. Subsequently, the mechanisms of autonomic modulation of cardiac excitability in health and in disease that causes arrhythmias will be discussed. Then the rationale for various neuraaxial modulation approaches (stellate ganglionectomy, thoracic epidural anesthesia, spinal cord stimulation and vagal nerve stimulation) in reducing the risk of ventricular arrhythmias will be discussed. The efficacy of stellate ganglionectomy in humans including, feasibility, surgical techniques, and complications will be discussed.
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