Operative therapy of malignant ventricular rhythm disturbances

Pre- and postoperative electrophysiologic study (EPS), intraoperative cardiac mapping, and extended endocardial resection of scar (EER) has enabled us to identify subgroups among 94 patients who have had operation to control or prevent malignant ventricular arrhythmia. Operative mortality was 8.5% and cure or prevention of ventricular arrhythmia was accomplished in 92% of survivors. Group 1: 13 patients were resuscitated from "sudden death" due to ventricular fibrillation (VF). All had exercise-induced VF and/or ventricular tachycardia (VT). Preoperative EPS revealed no inducible VT/VF. All had coronary artery disease, without evidence of myocardial infarction (MI) or ventricular wall motion abnormality; all were cured with conventional myocardial revascularization. Group 2: 65 patients had MI with residual left ventricular wall motion abnormality, usually aneurysm. The malignant arrhythmia, either sustained VT (38 patients) or VF (27 patients), was inducible by EPS but not usually by exercise, and all were refractory to medical therapy. Treatment was operative mapping, aneurysmectomy, EER, and coronary revascularization. Operative mortality was 11.9%; 90% of survivors are arrhythmia free, off drugs; 10% are now drug responsive. Group 3: 3 patients without coronary disease had VT or VF caused by endocardial sarcoidosis or operative scar from a previous congenital heart operation. Treatment was EPS, operative mapping, and excision of abnormal endocardial scar with no operative mortality. Group 4: 13 patients underwent aneurysmectomy for indication other than arrhythmia, but had preoperative ventricular irritability which was not life-threatening. Operation was aneurysmectomy, prophylactic EER, and revascularization with no mortality and no postoperative arrhythmic events. After many years of unpredictable and unsatisfactory results from various empirical surgical approaches, the operative treatment of malignant ventricular arrhythmia is now based on sound electrophysiologic principles.