Surgery for ventricular tachycardia of left ventricular origin: risk factors for success and long-term outcome
Ulrich Otto von Oppell1, Dave Milne, Andrzej Okreglicki
1Department of Cardiothoracic Surgery, Cardiac Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK. uvonopp@uhw-tr.wales.nhs.uk
Insights
Direct ventricular tachycardia (VT) surgery is a viable option for patients with drug-refractory VT of left ventricular origin when implantable cardioverter-defibrillators are not feasible. This surgical approach improved ejection fraction and offered long-term freedom from VT recurrence in survivors.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Sustained monomorphic ventricular tachycardia (VT) of left ventricular origin poses significant management challenges.
- Economic factors and patient-specific conditions often preclude the use of implantable cardioverter-defibrillators (ICDs).
- Direct VT surgery offers an alternative for patients with failed medical therapy or life-threatening arrhythmias.
Purpose of the Study:
- To review outcomes of direct VT surgery in 26 patients with left ventricular VT.
- To evaluate the efficacy and safety of surgical interventions for drug-refractory VT.
- To identify factors influencing outcomes in patients undergoing direct VT surgery.
Main Methods:
- Intraoperative mapping, endocardial resection, cryoablation, left ventricular remodeling, and coronary artery bypass grafting were employed.
- Surgical principles included addressing left ventricular aneurysms and performing endoaneurysmorrhaphy.
- Patient data were analyzed to assess operative mortality, VT recurrence, and long-term survival.
Main Results:
- Non-ischaemic VT patients had better preoperative characteristics and no operative mortality or recurrence.
- Ischaemic VT patients experienced an 8.3% operative mortality; risk factors included concomitant valve surgery and intra-aortic balloon pump use.
- Surgery significantly improved left ventricular ejection fraction (28.4% to 43.2%), with 10-year freedom from VT recurrence at 78.8% in survivors.
- Urgent/emergent surgery for life-threatening VT was associated with lower 10-year survival (22.2%) compared to elective procedures (73.3%).
Conclusions:
- Direct VT surgery is a valuable therapeutic option for symptomatic, drug-refractory VT originating from the left ventricle.
- The surgical approach can lead to significant improvement in left ventricular function and long-term arrhythmia control.
- Careful patient selection and surgical strategy are crucial, particularly differentiating between urgent and elective cases.
Objectives:
To review 26 consecutive patients with sustained monomorphic ventricular tachycardia (VT) of left ventricular origin, who underwent direct VT surgery.
Methods:
Economic factors precluded the use of an implantable cardioverter defibrillator (ICD) in the majority of these patients, and the indication for surgery in 81% of patients was for failed medical drug therapy and 27% of patients had frequent or incessant life-threatening VT. The principles of direct VT surgery included intraoperative mapping, extended endocardial resection, cryoablation, left ventricular aneurysm repair by left ventricular remodelling and endoaneurysmorrhaphy, as well as coronary artery bypass grafting.
Results:
Two patients with non-ischaemic VT were significantly younger (37.7 +/- 19.4 years, P = 0.03), had lower preoperative New York Heart Association class (P = 0.03), and had better left ventricular ejection fractions of 59.5 +/- 2.1% (P = 0.001) than the 24 ischaemic patients. No operative mortality or recurrence of VT occurred in this group. Ischaemic VT patients had an operative mortality of 8.3%; risk factors were concomitant valve surgery (P = 0.02), and perioperative intra-aortic balloon pump (P = 0.02). Surgery improved the left ventricular ejection fraction from 28.4 +/- 9.8% to 43.2 +/- 8.2% (P = 0.0001). Freedom from recurrence or inducibility of VT in operative survivors was 78.8 +/- 9.6% at 10 years; risk factors were arrhythmic focus remote to the left ventricular aneurysm (P = 0.015), and simple cryoablation or endocardial resection alone and not in combination (P = 0.003). Survival was 54.1 +/- 11.6% and 43.3 +/- 13.4% at 5 and 10 years, respectively, and there were no arrhythmic or sudden cardiac deaths. Patients with immediately life-threatening VT unsuitable for ICD implantation requiring urgent or emergent VT surgery had a 10-year survival of 22.2 +/- 13.9% compared to the more elective surgical group with a rate of 73.3 +/- 13.9% (P = 0.08).
Conclusions:
Direct VT surgery should remain an objective for symptomatic drug refractory VT of left ventricular origin.
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