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653 Two years later, the patient experienced ICD shocks due to VF triggered by emotional stress. She was offered bilateral cardiac sympathetic denervation (CSD), which had not yet been per­ formed in Poland in adults for arrhythmic indi­ cations. The patient was referred to a regional thoracic surgery center experienced in video­ ­assisted thoracoscopic CSD in hyperhidrosis and Raynaud disease. Although left CSD was considered, recent studies and persistent cold­ ness in the upper extremities supported the use of a bilateral approach.2 Bilateral CSD was per­ formed within 60 minutes with a single ­port access for each site from the third intercostal space in the medial axillary line. Sympathetic ganglia and fibers were removed from the level of Th1 to Th5, with the upper level of right ­sided dissection marked with a titanium clip used for bleeding prevention (FIGURE 1B). The results were confirmed histologically (FIGURE 1C). Interesting­ ly, the patient reported an immediate change in temperature perception, allowing her to stop wearing gloves at temperatures below 10°C de­ spite continued β ­blocker therapy. There were no ICD interventions during the 6­month follow ­up. Our case demonstrates several pitfalls of CPVT management. First, the CPVT diagnosis was delayed owing to incomplete workup dur­ ing the initial hospitalization. The exercise test was only performed at follow ­up to confirm an­ tiarrhythmic efficacy of metoprolol.1 Secondly, whereas in the largest pediatric CPVT registry, flecainide and CSD were used in 24% and 8% of patients, respectively,3 nadolol and flecainide Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disease linked to syncope, bidirectional or polymorphic ventricular tachycardia (bidVT/pVT), ventricu­ lar fibrillation (VF), and sudden cardiac death during exercise or emotional stress in patients without organic heart disease.1 There are sever­ al diagnostic and therapeutic options, although their availability in different countries is limited. We present a case of a 30­year ­old white wom­ an after aborted cardiac arrest, which occurred at her brother’s funeral. During hospitaliza­ tion, bidVT/pVT and VF reoccurred, requiring 5 defibrillations. Serial electrocardiograms re­ vealed no features of short QT, long QT, or Bru­ gada syndrome, whereas telemetry and Holt­ er recordings documented bidVT/pVT runs (FIGURE 1A). Echocardiography and coronary angiogra­ phy were normal. A single ­chamber ProMRI® implantable cardioverter defibrillator (ICD; Iforia 5 VR ­T, Biotronik, Berlin, Germany) was implanted, and the patient was discharged on metoprolol (50 mg twice daily) with recommendations for genetic and family screening. Until now, only her 6­year ­old daughter was screened (no ab­ normalities were detected), as no other family members agreed to be screened. Genetic test­ ing is still underway due to lack of reimburse­ ment. Although a follow ­up exercise test re­ vealed no significant arrhythmia, the patient still complained of cold sensation in the up­ per extremities, which she linked to meto­ prolol use. Correspondence to: Agnieszka Zienciuk ‐Krajka, MD, PhD, Department of Cardiology and Electrotherapy, Medical University of Gdańsk, ul. Dębinki 7, 80‐952 Gdańsk, Poland, phone: +48 58 349 39 20, email: agzien@gumed.edu.pl Received: April 19, 2019. Revision accepted: April 29, 2019. Published online: June 25, 2019. Kardiol Pol. 2019; 77 (6): 653‐654 doi:10.33963/KP.14834 Copyright by Polskie Towarzystwo Kardiologiczne, Warszawa 2019 C L I N I C A L V I G N E T T E

Bilateral cardiac sympathetic denervation in catecholaminergic polymorphic ventricular tachycardia