Technique of Left Cardiac Sympathetic Denervation (LCSD):
All children were operated under general anesthesia in left lateral position. Muscle sparing left posterolateral thoracotomy was performed through 3rd or 4th intercostal space. Pleura was opened and lung was retracted to expose the posterior mediastinal pleura. Descending thoracic aorta is identified. A small incision is placed just lateral to the aorta in the pleura at the level of crossing of 1st superior intercostal vein. Chain of thoracic sympathetic ganglia are identified along with stellate ganglion (Fused ganglion of lower cervical and upper T1 ganglia). Chain is exposed till T4 or T5 (Fig.4). Left cardiac sympathetic denervation is performed by removing lower half of stellate ganglion and upper thoracic ganglia (T1-T4/5). Excised nerve tissue is sent for histopathology for confirmation.
Posterior mediastinal pleura is loosely approximated. One child had additional PDA which was ligated. Pericardium is opened at the anterior border and epicardial pacing leads were placed and pulse generator was positioned in the pleural cavity by suturing it to the thoracic wall. Thoracotomy is closed in a usual layered manner after placing left pleural drain. Patients are usually weaned early and extubated within few hours after shifting to the intensive care unit.