Cryosurgery for ventricular bigeminy using a transaortic closed ventricular approach

Disabling monomorphic ventricular bigeminy has not been described as an indication for surgery. Three young patients with this arrhythmia sometimes deteriorating into ventricular tachyarrhythmias and in whom drug therapy failed completely were accepted for surgical ablation of the arrhythmogenic area. The earliest endocardial site of origin was located preoperatively by catheter mapping of the spontaneously occurring ventricular bigeminy in the left and right ventricles. For maximum preservation of myocardial muscle and function, the preoperative mapping and surgical procedure were performed through the aortic root; mapping by transaortic multipolar balloon was done during normothermic coronary perfusion and cryocoagulation was done during cardioplegic arrest. Cryocoagulation of the endocardial site was performed using the transaortic approach and epicardial cryocoagulation at the opposite site was done afterwards. In the two patients in whom the preoperative mapping results were consistent with those of preoperative catheter mapping, the arrhythmia could be abolished, as documented during long-term follow-up. In the only patient in whom the mapping results were not in agreement, the ventricular arrhythmia reoccurred and was the cause of death at five months after surgery. Postoperative wall-motion studies performed in the two surviving patients showed limited scars in the area of cryocoagulation and minor damage to the coronary arteries in that area. The transaortic approach can be considered as a new and important surgical option for endocardial mapping and cryocoagulation which prevents the damaging effects of a left ventriculotomy.