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Surgical cryoablation for ventricular tachyarrhythmia arising from the left ventricular outflow tract region
Eue-Keun Choi1, Koichi Nagashima2, Kaity Y Lin2
1Cardiac Arrhythmia Division, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
Insights
Surgical cryoablation offers a potential solution for drug-resistant ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT) when other methods fail. While effective for many, it carries risks including coronary injury.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) can be challenging to ablate due to anatomical barriers like epicardial fat or coronary arteries.
- Conventional catheter ablation may be ineffective for VAs in this difficult-to-reach region.
Observation:
- This study describes the application of surgical cryoablation for highly symptomatic VAs originating from the LVOT in patients refractory to catheter ablation.
- Four patients underwent the procedure between March 2009 and 2014.
Findings:
- Surgical cryoablation was successful in 3 out of 4 patients, leading to significant reduction or abolition of symptomatic VAs during a mean follow-up of 22 months.
- Potential complications include coronary artery injury, development of left ventricular systolic dysfunction, and atrioventricular block.
Implications:
- Surgical cryoablation presents a viable alternative for select patients with drug-resistant LVOT VAs.
- Careful patient selection and procedural planning are crucial due to the associated risks and variable efficacy.
Background:
Ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) region can be inaccessible for ablation because of epicardial fat or overlying coronary arteries.
Objective:
We describe surgical cryoablation of this type of VA.
Methods:
From March 2009 to 2014, 190 consecutive patients with VAs originating from the LVOT underwent ablation at our institution. Four patients (2%) underwent surgical cryoablation for highly symptomatic VAs after failing catheter ablation.
Results:
In all patients, endocardial or percutaneous epicardial mapping was consistent with origin in the LVOT. In 2 patients, the points of earliest activation during VAs were marked with a bipolar pacing lead in the overlying cardiac vein for guidance during surgery. Surgical cryoablation was successful in 3 of the 4 patients. The fourth patient subsequently had successful endocardial catheter ablation. During a mean follow-up of 22 ± 16 months (range 4-42 months), all patients showed abolition of or marked reduction in symptomatic VA. However, 1 patient subsequently required percutaneous intervention to the left anterior descending coronary artery; another developed progressive left ventricular systolic dysfunction caused by nonischemic cardiomyopathy; and a third patient underwent permanent pacemaker implantation because of complete atrioventricular block after concomitant aortic valve replacement.
Conclusion:
Surgical cryoablation is an option for highly symptomatic drug-resistant VAs emanating from the LVOT region. Despite extensive preoperative mapping, the procedure is not effective for all patients, and coronary injury is a risk.
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