[Surgical possibilities in the treatment of ventricular tachycardia]

Medical therapy for recurrent sustained ventricular tachycardia is often disappointing. We report on the direct i.e. electrophysiologically guided surgical approach to 44 patients with sustained ventricular tachycardia. 43 patients had previous myocardial infarction, one patient had arrhythmogenic right ventricular dysplasia. During preoperative electrophysiologic study, sustained ventricular tachycardia was induced in 41 patients, three patients had an incessant sustained ventricular tachycardia. 30 patients underwent endocardial catheter mapping. In 28 of 30 cases, the earliest endocardial activation during ventricular tachycardia was detected. Intraoperative mapping was performed in 42 patients, in two cases surgical approach was guided by the result of endocardial catheter mapping. In 34 patients endocardial mapping revealed the earliest site of ventricular tachycardia, in eight patients the arrhythmogenic area was identified by mapping during sinus rhythm. An encircling endocardial ventriculotomy was performed in 14 patients, whereas 29 patients underwent a circumscribed endocardial resection. A cryosurgical technique was performed in the patient with arrhythmogenic right ventricular dysplasia. The hospital mortality rate was 16% (seven of 42 patients), in one patient the cause of death was ventricular fibrillation. The late mortality rate is 14% (five of 37 patients), one patient had sudden cardiac death. Two patients had a recurrence of ventricular tachycardia postoperatively. In one of these an antitachycardia pacemaker was implanted, the other was successfully reoperated with endocardial resection. Postoperatively, a sustained ventricular tachycardia was inducible by programmed stimulation in three patients. Complex ventricular ectopic activity was found in ten patients, all of these were administered antiarrhythmic drugs. With respect to the poor prognosis of medically refractory ventricular tachycardia, we conclude that the electrophysiologically guided surgical approach has become an acceptable therapeutical alternative.