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Long-term surgical results in sudden death syndrome associated with cardiac dysfunction after myocardial infarction
H Bolooki1, M D Horowitz, A Interian
1Division of Thoracic, University of Miami School of Medicine, Florida 33101.
Insights
Map-guided cryoablation combined with surgical remodeling significantly improved cardiac event-free survival in patients with ventricular tachyarrhythmias. This approach reduced sudden cardiac death and the need for automatic implantable cardioverter-defibrillators (AICDs).
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Ventricular tachyarrhythmias post-myocardial infarction are life-threatening.
- Drug therapy is often ineffective for patients with coronary disease and left ventricular dysfunction.
- Electrophysiologic studies (EPS) guide treatment decisions.
Purpose of the Study:
- To evaluate surgical outcomes in patients with inducible ventricular tachyarrhythmias.
- To compare different surgical strategies including left ventricular remodeling, coronary artery bypass grafting, and automatic implantable cardioverter-defibrillator (AICD) implantation.
- To assess the efficacy of map-guided cryoablation in managing these complex cardiac conditions.
Main Methods:
- Retrospective review of 170 patients unresponsive to drug therapy.
- Surgical groups included: left ventricular remodeling with map-guided cryoablation and bypass (Group A), remodeling and bypass without cryoablation (Group B), bypass with AICD (Group C), and AICD only (Group D).
- Intraoperative EPS guided procedures and post-operative follow-up assessments.
Main Results:
- Map-guided cryoablation (Group A) showed significantly improved 6-year cardiac-event-free survival (80%) compared to other groups (p < 0.001).
- Group A had no sudden deaths and no need for AICD post-operatively.
- Groups C and D (AICD-based therapies) had lower cardiac-event-free survival rates (38% and 24%, respectively).
Conclusions:
- Map-guided ablative procedures combined with surgical remodeling offer superior long-term outcomes for ventricular tachyarrhythmias.
- This integrated approach reduces sudden cardiac death and reliance on AICDs.
- Surgical intervention tailored by electrophysiologic mapping is crucial for managing refractory ventricular arrhythmias.
Abstract:
To evaluate the surgical results in patients with inducible ventricular tachyarrhythmias due to coronary disease and left ventricular dysfunction, the authors reviewed their experience in 170 patients who had survived one or more cardiac arrests after myocardial infarction and were unresponsive to drug therapy based on electrophysiologic studies (EPS). There were nine operative deaths (5%). Based on intraoperative EPS, surgical remodeling of left ventricular dysfunction (aneurysm resection, infarct debulking, and septal reinforcement) with map-guided cryoablation and coronary artery bypass graft was performed in 34 patients (group A), and left ventricular remodeling and coronary artery bypass graft without guided endocardial resection was performed in 25 patients (group B). Forty-three patients (group C) had coronary artery bypass graft with implantation of an automatic implantable cardioverter defibrillator (AICD). Group D (68 patients) received AICD only. After operation, based on EPS results, four patients in group A (12%) and three patients in Group B (15%) required AICD implantation. Overall survival at 6 years was 65%, 48%, 85%, and 58% in patient groups A, B, C, and D, respectively (p = not significant). During follow-up in group A patients, none died suddenly and none needed AICD. In group B, two patients required AICD 3 and 5 years later, and five patients died suddenly. The incidence of sudden death was 2.3%/patient/year and 3.5%/patient/year after AICD implantation (groups C and D). At 6 years, cardiac-event-free survival was 80% and 70% for groups A and B and 38% and 24% for groups C and D, respectively (p less than 0.001). Patients receiving map-guided ablative procedures had significantly improved cardiac-event-free survival rates.