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Circulation. 2018;138:e272–e391. DOI: 10.1161/CIR.0000000000000549 September 25, 2018 e297 CLINICAL STATEMENTS AND GUIDELINES related to ischemia caused by anomalous origin of a coronary artery, repair or revascularization is performed to alleviate ischemia and reduce the recurrence of VA.S5.5-6,S5.5-7,S5.5-12–S5.5-14 5.5.1 Surgery for Arrhythmia Management Recommendation for Surgery for Arrhythmia Management References that support the recommendation are summarized in Online Data Supplement 12. COR LOE Recommendation IIb C-LD 1. In patients with monomorphic VT refractory to antiarrhythmic medications and attempts at catheter ablation, surgical ablation may be reasonable.S5.5.1-1–S5.5.1-7 Recommendation-Specific Supportive Text 1. Cardiac surgery as a standalone procedure for VT is rarely performed, but has a role in some highly symptomatic patients, when antiarrhythmic medications and catheter ablation fails or are not possible, particularly if the failure of ablation is due to an arrhythmia arising from an area that is inaccessible to catheter ablation, such as deep in the myocardium, beneath epicardial fat, or near the coronary arteries. Surgical ablation of tachycardia can also be performed at the time of other cardiac surgical interventions, such as during surgical resection of large aneurysms due to prior MI in which the border zone is often a substrate for VT, or placement of an LV assist device (LVAD).S5.5.1-5–S5.5.1-7 The procedure requires detailed characterization of the arrhythmia usually with preoperative imaging and mapping, therefore, surgical ablation is best undertaken at tertiary referral centers and with collaboration between experienced surgeons and electrophysiologists. 5.6 Autonomic Modulation Recommendations for Autonomic Modulation References that support the recommendations are summarized in Online Data Supplements 13 and 14. COR LOE Recommendations IIa C-LD 1. In patients with symptomatic, non–lifethreatening VA, treatment with a beta blocker is reasonable.S5.6-1 IIb C-LD 2. In patients with VT/VF storm in whom a beta blocker, other antiarrhythmic medications, and catheter ablation are ineffective, not tolerated, or not possible, cardiac sympathetic denervation may be reasonable.S5.6-2–S5.6-4 Synopsis Sympathetic activation is proarrhythmic and parasympathetic activation is generally antiarrhythmic in VT/VF. Modulating the autonomic nervous system for the purpose of preventing arrhythmias is an emerging therapeutic modality. For the prevention of VA, autonomic modulation can be done either through interruption of sympathetic outflow to the heart, pharmacological beta blockade, or through stimulation of the parasympathetic pathway (eg, vagal nerve stimulators, spinal cord stimulators). Although autonomic modulation has proven efficacy for certain conditions such as long QT syndrome and catecholaminergic polymorphic ventricular tachycardia (see Section 7.9), evidence is limited for its applicability to the broader group of VA, but studies are ongoing. Currently, there are limited data on the role of vagal nerve stimulators and spinal cord stimulators for the prevention of VA/SCD in humans, and thus no formal recommendation could be supported.S5.6-5 Recommendation-Specific Supportive Text 1. Many patients with non–life-threatening VA require only reassurance, but others have symptoms that warrant therapy. A small RCT of patients with symptomatic VA demonstrated a significant reduction in the arrhythmic burden with atenolol.S5.6-1 2. VT/VF storm causes significant morbidity and is associated with increased mortality. For VT/ VF storm refractory to treatment (medications, catheter ablation), cardiac sympathetic denervation has been shown in several small, observational studiesS5.6-3,S5.6-6 and 1 RCTS5.6-4 to reduce the arrhythmia burden. This has been shown for left or bilateral cardiac sympathetic denervation, and it has been suggested that bilateral cardiac sympathetic denervation may be superior.S5.6-3 Although data are limited, the significant morbidity and limited options in these patients make cardiac sympathetic denervation a reasonable option in selected patients. 6 Acute Management of Specific VA Recommendations for Management of Cardiac Arrest References that support the recommendations are summarized in Online Data Supplements 15 and 16. COR LOE Recommendations I A 1. CPR should be performed in patients in cardiac arrest according to published basic and advanced cardiovascular life support algorithms.S6-1–S6-3 I A 2. In patients with hemodynamically unstable VA that persist or recur after a maximal energy shock, intravenous amiodarone should be administered to attempt to achieve a stable rhythm after further defibrillation.S6-1,S6-4–S6-6 Downloaded from http://ahajournals.org by on October 7, 2026