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 In patients with monomorphic VT refractory to antiarrhythmic medications and attempts at catheter ablation, surgical ablation may be 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 antiarrhyth- mic medications and catheter ablation fails or are not possible, particularly if the failure of abla- tion 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 dur- ing surgical resection of large aneurysms due to prior MI in which the border zone is often a sub- strate for VT, or placement of an LV assist device 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 In patients with symptomatic, non life- threatening VA, treatment with a beta blocker is reasonable.S5.6-1 IIb C-LD 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 Synopsis Sympathetic activation is proarrhythmic and parasym- pathetic activation is generally antiarrhythmic in VT/VF. Modulating the autonomic nervous system for the pur- pose of preventing arrhythmias is an emerging thera- peutic modality. 