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Prophylactic automatic implantable cardioverter-defibrillator patches in patients at high risk for postoperative
A S Manolis1, H Rastegar, N A Estes
1Department of Medicine, Tufts University School of Medicine, New England Medical Center, Boston, Massachusetts 02111.
Insights
Prophylactic patches for automatic implantable cardioverter-defibrillators (AICD) were placed without the device in high-risk patients. This strategy showed mixed results in preventing inducible ventricular arrhythmias post-surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Patients with coronary artery disease undergoing cardiac surgery are at risk for ventricular arrhythmias.
- Preoperative sustained ventricular tachycardia or fibrillation, refractory to antiarrhythmic drugs, indicates high risk.
- Subendocardial resection patients with unmappable tachycardia or posterior aneurysm also face arrhythmia risks.
Purpose of the Study:
- To evaluate the efficacy of prophylactic automatic implantable cardioverter-defibrillator (AICD) patches placed without the device in patients at risk for postoperative ventricular arrhythmias.
- To assess the impact of this strategy on arrhythmia inducibility and the need for subsequent AICD implantation or medical management.
Main Methods:
- A prophylactic strategy of placing AICD patches without the device was used in 34 high-risk patients undergoing coronary bypass graft surgery or subendocardial resection.
- Patient selection was based on preoperative sustained ventricular arrhythmias and drug-refractory status.
- Arrhythmia inducibility was assessed postoperatively, with subsequent AICD implantation or medical therapy for inducible arrhythmias.
Main Results:
- Surgical mortality was 12%.
- Among survivors of coronary bypass surgery, 60% (6/10) had non-inducible ventricular arrhythmias postoperatively.
- Among survivors of subendocardial resection, 75% (15/20) had non-inducible ventricular arrhythmias postoperatively.
- A subset of patients with persistent inducible arrhythmias required AICD implantation or continued medical management.
Conclusions:
- Prophylactic AICD patches without the device may reduce inducible ventricular arrhythmias in some patients undergoing cardiac surgery.
- The strategy's effectiveness varies between surgical procedures, with a higher success rate observed after subendocardial resection.
- Further investigation is warranted to optimize patient selection and management strategies for preventing postoperative ventricular arrhythmias.
Abstract:
The strategy of placing prophylactic patches for the automatic implantable cardioverter-defibrillator (AICD) without the AICD was employed in 34 patients with coronary artery disease at risk for postoperative ventricular tachycardia undergoing coronary bypass graft surgery (12 patients) or subendocardial resection (22 patients). Patients were selected on the basis of the presence of preoperative sustained ventricular tachycardia (25 patients) or ventricular fibrillation (9 patients) and absence of control of the arrhythmia with 3.6 +/- 1.3 antiarrhythmic drugs by programmed stimulation. Patients having subendocardial resection were also selected on the basis of multiple configurations of ventricular tachycardia, inability to map the tachycardia or posterior wall aneurysm. The surgical mortality rate was 12%, with two deaths after coronary bypass graft surgery and two deaths after subendocardial resection. The AICD patches were removed in 1 of the 34 patients a few hours after surgery because of left atrial laceration and bleeding. Among 10 patients surviving coronary bypass surgery alone, ventricular arrhythmia was not inducible in 6 and in 4 it remained inducible postoperatively. One of the four patients with inducible arrhythmia had the AICD implanted with use of local anesthesia; the other three were treated with drugs. Among 20 patients surviving subendocardial resection, ventricular arrhythmia was noninducible in 15 and remained inducible in 5. Three of these five patients had an AICD implanted; the other two were treated with drugs. At 12 +/- 7 month follow-up, there were no late deaths.(ABSTRACT TRUNCATED AT 250 WORDS)