Left cardiac sympathetic denervation in patients with heart failure: a new indication for an old intervention?

Heart failure (HF) is characterized by an autonomic imbalance with withdrawal of vagal activity and increased sympathetic activity. Novel non-pharmacological approaches to HF aimed at increasing vagal activity are being proposed. Left cardiac sympathetic denervation (LCSD) has been shown to modify favorably the outcome of several disorders characterized by life-threatening arrhythmias triggered by increased sympathetic activity. The present manuscript discusses the rationale and the limited experimental and clinical experience suggesting a potential role for LCSD in the treatment of patients with advanced heart failure. Possible future clinical applications of LCSD may include HF patients who are intolerant to β-adrenergic blockade, HF patients who have frequent implantable cardioverter-defibrillator shocks, and HF patients in countries where the likelihood of receiving a device is limited, but the capability to perform a one in a lifetime procedure is present.