Surgical Techniques and Nuances for Superior Cervical Ganglionectomy and Decentralization in Rats.

The sympathetic nervous system has been implicated in various physiological and pathological processes, including regulation of homeostatic functions, maintenance of the circadian rhythms, and neuronal disruption and recovery after injury. Of special interest is focus on the role of the superior cervical ganglion (SCG) in regulating the daily changes in pineal function. Removal of the superior cervical ganglion (SCGx) and decentralization have served as valuable microsurgical models to investigate the effects of surgical denervation on this gland or organ. In this chapter, we offer information about methodologies for performing SCGx along with decentralization and denervation procedures, including details about recommended equipment as well as tips that can improve these techniques.

Limited Left Thoracoscopic Sympathectomy Effectively Silences Refractory Electrical Storm.

BACKGROUND: An electrical storm (ES) is a life-threatening condition that affects up to 20% of patients with implantable cardioverter defibrillators. In this small retrospective study, we report our results with left video-assisted thoracoscopic sympathectomy/ganglionectomy (VATSG) to treat refractory ES in low-ejection fraction patients who were not candidates for catheter ablation. METHODS: We identified 12 patients who presented with ES and underwent a total of 14 video-assisted thoracoscopic sympathectomy/ganglionectomy, including 3 patients on venoarterial extracorporeal membrane oxygenation. We reviewed demographic data, survival to discharge, number of cardioversions (before and after VATSG), need for readmissions, and need for right-sided procedures. RESULTS: In the 30 days before a left VATSG, mean number of shocks was 22.67 for all patients. For the patients who survived to discharge, the mean was 3.55 since surgery and the median was zero shocks after a median follow-up of 358 days. Six patients did not experience further cardioversions since the last VATSG and 5 were not readmitted for ventricular tachycardia. Two patients had staged bilateral procedures owing to recurrences; of those, 1 did not require further cardioversions. CONCLUSIONS: Limited left VATSG is an appropriate and effective initial treatment for ES patients who are not candidates for catheter ablation, including those on venoarterial extracorporeal membrane oxygenation for hemodynamic support.

Percutaneous Full-Endoscopic C2 Ganglionectomy for the Treatment of Intractable Occipital Neuralgia: Technical Note.

BACKGROUND: The C-2 dorsal root ganglionectomy procedure can provide effective treatment for intractable occipital neuralgia (ON). However, the traditional microsurgery of C2 ganglionectomy needs a wide incision and significant paraspinous muscle dissection for adequate visualization. The indications of endoscopic spine surgery are ever expanding, with the development of endoscopic armamentaria and technological innovations. OBJECTIVE: To validate the feasibility of the approach and describe several operative nuances based on the authors' experience. In this paper, the authors describe a patient with intractable ON who was successfully treated with a percutaneous full-endoscopic C2 ganglionectomy. METHODS: We describe the case of an 83-yr-old female with a 2-yr history of left ON who did not respond to a series of treatments, including physical therapy, drug therapy, injection therapy, and radiofrequency therapy. After careful examination, we performed a percutaneous, full-endoscopic left C2 ganglionectomy. RESULTS: The patient was successfully treated with a percutaneous full-endoscopic ganglionectomy. Afterwards, her intractable and constant pain was relieved. There was no cerebrospinal fluid leakage, incision infection, neck deformity, or other complications. CONCLUSION: C2 ganglionectomy can be accomplished successfully using a full-endoscopic uniportal surgical technique under continuous irrigation, which has the advantages of excellent illumination and visualization, reduced surgery-related trauma, and reduced bleeding.

An age-dependent outcome analysis of microvascular decompression and percutaneous thermocoagulation in trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) is a severe pain condition and the most common facial neuralgia. While microvascular decompression (MVD) presents an excellent treatment in neurovascular compression cases, percutaneous thermocoagulation (PT) of the ganglion Gasseri is an alternative option. This study aimed to evaluate post-operative complication rate and outcome of both treatment strategies related to the patient's age. METHODS: The medical records of all patients with the diagnosis of trigeminal neuralgia undergoing an MVD or PT of the ganglion Gasseri (between January 2007 and September 2017) were reviewed to determine the efficacy and the complication rate of both methods in regard to the patient's age. RESULTS: Seventy-nine patients underwent MVD surgery and 39 a PT. The mean age of patients in the MVD group was 61 years and 73 years in the PT group. There were 59 (50%) female patients. Nerve-vessel conflict could be identified in 78 (98.7%) MVD and 17 (43.6%) PT patients on preoperative MRI. Charlson comorbidity index was significantly higher in PT group (2.4 (1.8) versus 3.8 (1.8) p < 0.001). The Barrow pain score (BPS) at the last follow-up demonstrated higher scores after PT (p = 0.007). The complication rate was markedly higher in PT group, mostly due to the facial hypesthesia (84.6% versus 27.8%; p < 0.001). Mean symptom-free survival was significantly shorter in the PT group (9 vs. 26 months, p < 0.001). It remained statistically significant when stratified into age groups: (65 years and older: 9 vs. 18 months, p = 0.001). Duration of symptoms (OR 1.005, 95% CI 1.000-1.010), primary procedure (OR 6.198, 95% CI 2.650-14.496), patient age (OR 1.033, 95% CI 1.002-1.066), and postoperative complication rate (OR 2.777, 95% CI 1.309-5.890) were associated with treatment failure. CONCLUSION: In this patient series, the MVD is confirmed to be an excellent treatment option independent of patient's age. However, while PT is an effective procedure, time to pain recurrence is shorter, and the favorable outcome (BPS 1 and 2) rate is lower compared to MVD. Hence MVD should be the preferred treatment and PT should remain an alternative in very selected cases when latter is not possible but not in the elderly patient per se.

Minimally Invasive Bilateral Stellate Ganglionectomy for Refractory Ventricular Tachycardia.

Cardiac sympathetic denervation (CSD) for refractory ventricular tachycardia (VT) has been shown to decrease VT recurrence and defibrillator shocks in patients with ischemic and nonischemic cardiomyopathy. Here and in the accompanying Video, we demonstrate the technique for minimally invasive CSD, highlight important technical points, and report surgical outcomes. CSD is accomplished through bilateral resection of the inferior one-third to one-half of the stellate ganglion en bloc with T2-T4 sympathectomy. Despite the high potential for perioperative risk, most patients do not have serious complications. We find that surgical CSD can be performed safely in an attempt to liberate patients from refractory VT.

Renal Denervation and Celiac Ganglionectomy Decrease Mean Arterial Pressure Similarly in Genetically Hypertensive Schlager (BPH/2J) Mice.

Renal denervation (RDNX) lowers mean arterial pressure (MAP) in patients with resistant hypertension. Less well studied is the effect of celiac ganglionectomy (CGX), a procedure which involves the removal of the nerves innervating the splanchnic vascular bed. We hypothesized that RDNX and CGX would both lower MAP in genetically hypertensive Schlager (BPH/2J) mice through a reduction in sympathetic tone. Telemeters were implanted into the femoral artery in mice to monitor MAP before and after RDNX (n=5), CGX (n=6), or SHAM (n=6). MAP, systolic blood pressure, diastolic blood pressure, and heart rate were recorded for 14 days postoperatively. The MAP response to hexamethonium (10 mg/kg, IP) was measured on control day 3 and postoperative day 10 as a measure of global neurogenic pressor activity. The efficacy of denervation was assessed by measurement of tissue norepinephrine. Control MAP was similar among the 3 groups before surgical treatments (≈130 mm Hg). On postoperative day 14, MAP was significantly lower in RDNX (-11±2 mm Hg) and CGX (-11±1 mm Hg) groups compared with their predenervation values. This was not the case in SHAM mice (-5±3 mm Hg). The depressor response to hexamethonium in the RDNX group was significantly smaller on postoperative day 10 (-10±5 mm Hg) compared with baseline control (-25±10 mm Hg). This was not the case in mice in the SHAM (day 10; -28±5 mm Hg) or CGX (day 10; -34±7 mm Hg) group. In conclusion, both renal and splanchnic nerves contribute to hypertension in BPH/2J mice, but likely through different mechanisms.

The management of compensatory sweating after thoracic sympathectomy.

OBJECTIVE: The main therapeutic method of treatment for local hyperhidrosis is endoscopic thoracic sympathectomy. Generally, resections of the sympathetic trunk or ganglia are performed between the second rib and sixth rib. However, this procedure can result in compensatory sweating, in which excess sweating occurs on the back, chest, and abdomen. Compensatory sweating has been regarded as a thermoregulatory response and thought to be untreatable. This study suggests that compensatory sweating is not a physiologic reaction and is indeed treatable. METHODS: Eight patients with severe compensatory sweating were treated by observing blood perfusion of the skin with laser speckle flowgraphy, which determines the sympathetic nerves related to the area of skin with compensatory sweating. When intraoperative monitoring with laser speckle flowgraphy indicated the position of compensatory sweating by electrical stimulation of the sympathetic ganglion, ganglionectomy was performed. RESULTS: The skin domain that each sympathetic nerve controls was able to be detected by laser speckle flowgraphy. In all patients, compensatory sweating was resolved after interruption of the ganglia or sympathetic nerves related to compensatory sweating. CONCLUSIONS: Our results demonstrate that compensatory sweating is caused by denatured sympathetic nerves influenced by endoscopic thoracic sympathectomy and is not the result of a physiological response. With laser speckle flowgraphy, the sympathetic nerve related to the sweating of various parts of the body could be identified. The treatment of compensatory sweating on the back, chest, and stomach was previously considered to be difficult; however, compensatory sweating is demonstrated to be treatable with this technique.

Ultrasound-Guided Ganglionectomy of a Flexor Hallucis Longus Ganglion Cyst Using Coablation Technology: A Case Report.

A 44-year-old woman with a history of an open ganglionectomy 2 years prior presented with a recurrent ganglion cyst. The ganglion cyst, extending from the flexor hallucis longus tendon sheath, was confirmed with magnetic resonance imaging. The patient declined another surgical incision. An experimental procedure was performed: ultrasound-guided ganglionectomy using a coablation wand. She achieved full symptom resolution, with no recurrence 1 year afterwards. To our knowledge, this is the first case report in the literature describing the use of this instrument for treating a ganglion cyst.

Oxidative stress damage circumscribed to the central temporal retinal pigment epithelium in early experimental non-exudative age-related macular degeneration.

Non-exudative age-related macular degeneration (NE-AMD) represents the leading cause of blindness in the elderly. The macular retinal pigment epithelium (RPE) lies in a high oxidative environment because its high metabolic demand, mitochondria concentration, reactive oxygen species levels, and macular blood flow. It has been suggested that oxidative stress-induced damage to the RPE plays a key role in NE-AMD pathogenesis. The fact that the disease limits to the macular region raises the question as to why this area is particularly susceptible. We have developed a NE-AMD model induced by superior cervical ganglionectomy (SCGx) in C57BL/6J mice, which reproduces the disease hallmarks exclusively circumscribed to the temporal region of the RPE/outer retina. The aim of this work was analyzing RPE regional differences that could explain AMD localized susceptibility. Lower melanin content, thicker basal infoldings, higher mitochondrial mass, and higher levels of antioxidant enzymes, were found in the temporal RPE compared with the nasal region. Moreover, SCGx induced a decrease in the antioxidant system, and in mitochondria mass, as well as an increase in mitochondria superoxide, lipid peroxidation products, nuclear Nrf2 and heme oxygenase-1 levels, and in the occurrence of damaged mitochondria exclusively at the temporal RPE. These findings suggest that despite the well-known differences between the human and mouse retina, it might not be NE-AMD pathophysiology which conditions the localization of the disease, but the macular RPE histologic and metabolic specific attributes that make it more susceptible to choroid alterations leading initially to a localized RPE dysfunction/damage, and secondarily to macular degeneration.

Bilateral sympathetic stellate ganglionectomy attenuates myocardial remodelling and fibrosis in a rat model of chronic volume overload.

Reducing sympathetic neurohormone expression is a key therapeutic option in attenuating cardiac remodelling. Present study tested the feasibility of attenuating cardiac remodelling through reducing sympathetic neurohormone level by partial cardiac sympathetic denervation in a rat model of chronic volume overload. Male Sprague-Dawley rats were randomized into sham group (S, n = 7), aortocaval fistula group (AV, n = 7), and aortocaval fistula with bilateral sympathetic stellate ganglionectomy group (AD, n = 8). After 12 weeks, myocardial protein expression of sympathetic neurohormones, including tyrosine hydroxylase, neuropeptide Y, growth associated protein 43, and protein gene product 9.5, were significantly up-regulated in AV group compared to S group, and down-regulated in AD group. Cardiac remodelling was aggravated in AV group compared to S group and attenuated in AD group. The myocardial deposition of extracellular matrix, including collagen I and III, was enhanced in AV group, which was reduced in AD group. Myocardial angiotensin II and aldosterone expressions were significantly up-regulated in AV group and down-regulated in AD group. Our results show that bilateral sympathetic stellate ganglionectomy could attenuate cardiac remodelling and fibrosis by down-regulating sympathetic neurohormones expression in this rat model of chronic volume overload.

Arthroscopic Ganglionectomy in the Pediatric Population.

BACKGROUND: Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population. METHODS: All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics. RESULTS: There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again. CONCLUSION: Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Dorsal Capsular Defect and Synovial Fistula to the Fourth Extensor Compartment: A Late Complication after Arthroscopic Dorsal Wrist Ganglionectomy.

Arthroscopic dorsal wrist ganglionectomy is demonstrably a safe procedure with recurrence rates comparable to open surgery. We present a patient with wrist pain following arthroscopic ganglion excision. MRI and arthroscopic findings showed a large dorsal capsular defect, synovial fistula to the fourth extensor compartment, and dorsal radiocarpal ligament resection. Ligament reconstruction and capsular imbrication resolved her symptoms. We postulate that this complication resulted from a large capsular resection. Because we feel that it can be difficult to judge the size of the debridement through an arthroscope, the need for adequate capsular resection in dorsal wrist ganglionectomy needs to be balanced by consideration of potential complications from more aggressive capsular debridement, and thus we feel that capsular resection should be limited to no more than 1 cm2.

Sympathetic ganglionectomy for facial blushing using application of laser speckle flow graph.

OBJECTIVE: Endoscopic thoracic sympathectomy at the second rib level is considered effective as a therapeutic treatment for facial blushing. However, 10% to 15% of patients do not benefit from this intervention. No additional procedure has been developed for this disorder. Recently, ganglionectomy using application of laser speckle flow graph has been evaluated for the treatment of compensatory sweating. We report our results of ganglionectomy for facial blushing as a redo surgery. METHODS: Between August 2012 and April 2017, 8 patients with facial blushing who underwent an initial sympathectomy reported symptom recurrence. Seven patients had undergone transection of the sympathetic trunk at the second rib and 1 patient had undergone transection of the sympathetic trunk at the second and third ribs. These patients were treated using ganglionectomy guided by application of laser speckle flow graph. After temporary decreases in facial skin blood perfusion were confirmed by stimulating the sympathetic ganglions, ganglionectomy was performed. RESULTS: All patients' symptoms improved. There were no side effects, including deterioration of compensatory sweating, worsening of gustatory sweating, or Horner syndrome. There were no cases of mortality or conversion to open surgery. CONCLUSIONS: This study shows the effectiveness of ganglionectomy for the treatment of facial blushing, representing a new treatment option for this condition. Considering the mechanism of facial blushing, it is important to recognize that ganglionectomy is effective after the interception of the sympathetic trunk on the cranial side.

Bilateral superior cervical ganglionectomy attenuates the progression of ß-aminopropionitrile-induced aortic dissection in rats.

AIMS: Aortic dissection (AD) represents one of the most common aortic emergencies with high incidence of morbidity and mortality. Clinical studies have shown that the increased excitability of the sympathetic nerve may be associated with the formation of AD. In this study, we examined the effects of bilateral superior cervical sympathectomy (SCGx) on the progression of ß-aminopropionitrile (BAPN)-induced AD in rats. MAIN METHODS: Sprague-Dawley rats were randomly divided into three groups, including BAPN, BAPN+SCGx and control groups. For terminal measurements, the mean arterial pressure (MAP) and heart rate (HR) were monitored and the basal sympathetic nerve activity (SNA) was assessed through recording the variation in arterial pressure in response to hexamethonium application. Pathological changes in the aortic wall were observed by histological staining. Matrix metalloproteinase-2 (MMP-2) and MMP-9 concentrations within the aortic wall were analyzed by western blot. KEY FINDINGS: The results show that BAPN administration could elevate SNA and cause the formation of AD in rats with a high incidence (67.7%), while SCGx treatment inhibited the elevation of SNA and significantly reduced the incidence (20%). SCGx may suppress the formation of BAPN-induced AD via restraining the rise of HR and reducing the MMP-9 concentration in aortic wall. SIGNIFICANCE: These results indicate that surgical techniques such as sympathetic nerve block may be a potentially useful therapy for the prevention of AD.

Assessment of the effect of left atrial cryoablation enhanced by ganglionated plexi ablation in the treatment of atrial fibrillation in patients undergoing open heart surgery.

BACKGROUND: The aim of our study was to investigate, whether enhancement of left atrial cryoablation by ablation of the autonomic nervous system of left atrium leads to influencing the outcomes of surgical treatment of atrial fibrillation in patients with structural heart disease undergoing open-heart surgery. METHODS: The observed patient file consisted of 100 patients, who have undergone a combined open-heart surgery at our department between July 2012 and December 2014. The patients were indicated for the surgical procedure due to structural heart disease, and suffered from paroxysmal, persistent, or long-standing persistent atrial fibrillation. In all cases, left atrial cryoablation was performed in the extent of isolation of pulmonary veins, box lesion, connecting lesion with mitral annulus, amputation of the left atrial appendage and connecting lesion of the appendage base with left pulmonary veins. Furthermore, 35 of the patients underwent mapping and radiofrequency ablation of ganglionated plexi, together with discision and ablation of the ligament of Marshall (Group GP). A control group was consisted of 65 patients without ganglionated plexi intervention (Group LA). The main primary outcome was establishment and duration of sinus rhythm in the course of one-year follow-up. RESULTS: Evaluation of the number of patients with a normal sinus rhythm in per cent has shown comparable values in both groups (Group GP - 93.75%, Group LA - 86.67%, p = 0.485); comparable results were also observed in patients with normal sinus rhythm without anti-arrhythmic treatment in the 12th month (Group GP - 50%, Group LA - 47%, p = 0.306). We have not observed any relation between the recurrence of atrial fibrillation and the presence of a mitral valve surgery, or between the presence of a mitral and tricuspid valves surgery and between the left atrial diameter > 50 mm. CONCLUSIONS: Enhancement of left atrial cryoablation by gangionated plexi ablation did not influence the outcomes of surgical ablation due to atrial fibrillation in our population in the course of 12-month follow-up. TRIAL REGISTRATION: The study was approved retrospectively by the Ethics Committee of the University Hospital Ostrava ( reference number 867/2016).

Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation.

INTRODUCTION:: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS:: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS:: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION:: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Left atrial ganglionated plexi detection is related to heart rate and early recurrence of atrial fibrillation after surgical ablation

Abstract INTRODUCTION: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Role of surgical thoracic sympathetic interruption in treatment of facial blushing: a systematic review.

OBJECTIVES: This paper aims to review the evidence to support the effectiveness of sympathectomy as a treatment for facial blushing in terms of relief of facial blushing, patient satisfaction, recurrence of blushing, patients regretting treatment and its associated complications. METHODS: A systematic search strategy was performed in Ovid-Medline, Embase, Cochrane library and NICE. Studies reporting outcomes of sympathetic interruption in the treatment of facial blushing were retrieved. RESULTS: Nine studies met the inclusion criteria with 1369 patients included in the final analysis. The age range of patients was 8 to 74 years (from 7 studies) with 56% females. Mean follow up was 21 months in 8 studies (range 6 to 30 months). The pooled proportion of patients who had good relief of facial blushing was 78.30% (95% C.I. 58.20% - 98.39%). Complete satisfaction was reported in 84.02% (95% C.I. 71.71% - 96.33%). Compensatory sweating and gustatory sweating were the commonest complications occurring in 74.18% (95% C.I. 58.10% - 90.26%) and 24.42% (95% C.I. 12.22% - 36.61%) respectively. The estimated proportion of patients regretting surgery was 6.79% (C.I 2.08% 11.50%). CONCLUSION: Sympathetic interruption at T2 or T2-3 ganglia appears to be an effective treatment for facial blushing. However, lack of randomized trials comparing sympathetic interruption with non-surgical methods of treatment and heterogeneity of included studies with respect to assessment of outcome measures preclude strong evidence and definitive recommendations.

Vagal Reactions during Cryoballoon-Based Pulmonary Vein Isolation: A Clue for Autonomic Nervous System Modulation?

Although paroxysmal atrial fibrillation (AF) is known to be initiated by rapid firing of pulmonary veins (PV) and non-PV triggers, the crucial role of cardiac autonomic nervous system (ANS) in the initiation and maintenance of AF has long been appreciated in both experimental and clinical studies. The cardiac intrinsic ANS is composed of ganglionated plexi (GPs), located close to the left atrium-pulmonary vein junctions and a vast network of interconnecting neurons. Ablation strategies aiming for complete PV isolation (PVI) remain the cornerstone of AF ablation procedures. However, several observational studies and few randomized studies have suggested that GP ablation, as an adjunctive strategy, might achieve better clinical outcomes in patients undergoing radiofrequency-based PVI for both paroxysmal and nonparoxysmal AF. In these patients, vagal reactions (VR) such as vagally mediated bradycardia or asystole are thought to reflect intrinsic cardiac ANS modulation and/or denervation. Vagal reactions occurring during cryoballoon- (CB-) based PVI have been previously reported; however, little is known on resulting ANS modulation and/or prevalence and significance of vagal reactions during PVI with the CB technique. We conducted a review of prevalence, putative mechanisms, and significance of VR during CB-based PVI.