Surgical ablation of ventricular tachycardia with sequential map-guided subendocardial resection: electrophysiologic assessment and long-term follow-up
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D E Haines1, B B Lerman, I L Kron
1Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville 22908.
Insights
Sequential map-guided subendocardial resection effectively treats ventricular tachycardia in coronary artery disease patients, achieving high survival and excellent long-term arrhythmia control. This advanced surgical technique offers a promising solution for complex cardiac arrhythmias.
Area of Science:
- Cardiac Surgery
- Electrophysiology
- Cardiovascular Disease
Background:
- Sustained ventricular tachycardia (VT) in patients with coronary artery disease (CAD) poses significant management challenges.
- Conventional treatments often have limited efficacy or carry substantial risks for this patient population.
- Novel surgical approaches are needed to improve outcomes for refractory VT.
Purpose of the Study:
- To evaluate the efficacy and safety of a new sequential map-guided subendocardial resection (SER) technique for treating VT in CAD patients.
- To assess operative survival, arrhythmia recurrence, and long-term cardiac survival rates following SER.
Main Methods:
- A cohort of 45 consecutive patients with CAD-related VT underwent sequential map-guided SER or cryoablation during normothermic cardiopulmonary bypass.
- The procedure involved repeated cycles of VT induction, mapping, and resection/ablation until VT was no longer inducible.
- Postoperative electrophysiologic evaluation assessed arrhythmia inducibility off antiarrhythmic drugs.
Main Results:
- 91% of patients survived to hospital discharge, with 85% demonstrating no inducible VT postoperatively (off drugs).
- Long-term follow-up showed significant freedom from arrhythmic events (76% at 42 months).
- Operative survival was high, and cardiac survival was comparable to patients with similar left ventricular function but no prior VT.
Conclusions:
- Sequential map-guided SER is a safe and effective technique for managing sustained VT in patients with coronary artery disease.
- The procedure achieves high operative survival, excellent long-term arrhythmia control, and favorable cardiac survival rates.
- This technique offers a viable therapeutic option, particularly in the absence of preoperative cardiogenic shock.
Abstract:
A new operative technique of sequential map-guided subendocardial resection (SER) was used in 45 consecutive patients for the treatment of sustained ventricular tachycardia due to coronary artery disease. This technique is characterized by map-guided SER or cryothermic ablation during normothermic cardiopulmonary bypass, followed by repeated sequences of programmed stimulation to assess adequacy of resection. The patients' mean age was 59 +/- 10 years and the mean left ventricular ejection fraction was 34 +/- 12%. Twenty-five (56%) patients had a history of myocardial infarction within the previous 2 months. After ventriculotomy, 34 patients (76%) had inducible monomorphic ventricular tachycardia. These patients underwent repeated sequences of ventricular tachycardia induction and mapping during normothermic bypass followed by successive SER or cryothermic ablation until sustained monomorphic ventricular tachycardia was no longer inducible. Twenty-seven patients had a total of 60 discrete, mappable tachycardias induced and seven patients had 10 discrete tachycardias that were too fast to accurately map. In the remaining 11 patients, no ventricular tachycardia was inducible after ventriculotomy and SER, which included all visually identifiable scar, was performed. The mean cardiopulmonary bypass time was 102 +/- 27 min. Forty-one of 45 patients (91%) survived to hospital discharge, and 35 of 41 patients (85%) had no inducible ventricular tachycardia at postoperative electrophysiologic evaluation performed in the absence of all antiarrhythmic drugs. The remaining six patients had no inducible ventricular tachycardia with drug therapy. All four operative nonsurvivors had refractory cardiac collapse preoperatively. Over 19 +/- 12 months of follow-up, there were four sudden cardiac deaths and no nonfatal recurrences of ventricular tachycardia. There were seven additional cardiac deaths. Actuarial cardiac survival was 0.57, and freedom from arrhythmic events was 0.76 at 42 months. Thus, in the absence of cardiogenic shock, the technique of sequential map-guided SER achieves: (1) a high operative survival with acceptable perfusion times, (2) excellent long-term arrhythmia control, and (3) survival comparable to that in patients with similar left ventricular function and no history of ventricular tachyarrhythmia.