Chronic refractory angina pectoris treated by bilateral stereotactic radiosurgical stellate ganglion ablation: first-in-man case report

Miroslav Hudec; Otakar Jiravsky; Radim Spacek; Radek Neuwirth; Lukas Knybel; Libor Sknouril; Jakub Cvek; Roman Miklik

doi:10.1093/ehjcr/ytab184

Chronic refractory angina pectoris treated by bilateral stereotactic radiosurgical stellate ganglion ablation: first-in-man case report

Eur Heart J Case Rep. 2021 Aug 31;5(8):ytab184. doi: 10.1093/ehjcr/ytab184. eCollection 2021 Aug.

Authors

Miroslav Hudec^{1

2}, Otakar Jiravsky^{1

2}, Radim Spacek¹, Radek Neuwirth^{1

2}, Lukas Knybel³, Libor Sknouril¹, Jakub Cvek³, Roman Miklik¹

Affiliations

¹ Department of Cardiology, Nemocnice Agel Trinec-Podlesi, Konska 453, Trinec 739 61, Czechia.
² Faculty of Medicine, Masaryk University, Kamenice 735/5, Brno 625 00, Czechia.
³ Department of Oncology, University Hospital Ostrava, 17. listopadu 5, Ostrava 708 00, Czechia.

Abstract

Background: Refractory angina pectoris (AP) significantly impairs quality of life in patients with chronic coronary syndrome. Several minimally invasive methods (coronary sinus reducer, cell therapy, laser or shockwave revascularization, and spinal cord stimulation) or non-invasive methods (external counterpulzation) have been studied. However, their routine clinical use has not been widely implemented. Surgical or endoscopic sympathectomy is feasible for permanently relieving angina, but is often contraindicated due to the extent of complications associated with it. Neuromodulation by anaesthetic blockade of the left-sided stellate ganglion (SG) has been shown to relieve angina for days or weeks. To provide a long-term anti-anginal effect, novel pharmacological (phenol-based) or radiofrequency ablation techniques have been individually used to permanently destroy sympathetic pathways.

Case summary: We describe a first-in-man use of stereotactic radiosurgical SG ablation using a linear accelerator (CyberKnife) in a heart failure patient after myocardial infarction with chronic refractory AP. Repeated anaesthetic SG blockade in this patient resulted in a significant, but only short-term, clinical improvement. The left, and subsequently the right, SG was ablated by targeted irradiation. During the 1-year follow-up, the patient remained without angina. We did not observe any clinically relevant early or late complications. Atrial fibrillation that developed 2 months after the second procedure was deemed to be associated with a natural progression of co-existing heart failure.

Discussion: We conclude that stereotactic radiosurgical SG ablation has the potential to become a minimally invasive and low-risk procedure to treat refractory angina patients. However, this procedure needs to be evaluated in larger patient populations.

Keywords: Case report; Refractory angina; Stellate ganglion blockade; Stereotactic radiosurgery; Upper thoracic sympathetic system.

Publication types

Case Reports