Surgical treatment of ventricular tachycardia. Indications and results

Despite the excellent results achieved with the endocardial resection procedure in the management of patients with life-threatening ventricular tachycardia. Most surgical electrophysiology teams have experienced a decline in the number of direct operations performed for life-threatening ventricular tachycardia. This is probably due to the widespread use of thrombolytic therapy during the acute phase of infarct formation. But also to the advent of implantable cardioverter-defibrillators that are increasingly sophisticated, easy to use and effective. Their increased use over the past few years is related to the belief that direct operations for the eradication of ventricular tachycardia foci bear a high operative mortality rate. However, today the operative mortality is less than 5%, and long term survival is up to 85% at 5 years with an extremely low incidence of ventricular tachycardia recurrence and sudden death. We report the results obtained in our first 100 patients in whom ventricular tachycardia surgical ablation was guided by computerized mapping of both the endocardium and epicardium. A particular type of ventricular tachycardia activation pattern was found to be associated with a higher rate of electrical failure due to a deep septal substratum. Appropriate management of this condition may further decrease the rate of ventricular tachycardia reinducibility and long term return of ventricular tachycardia to a level yet unachieved by any other therapeutic modality. The results of catheter ablation are promising, but access to intramural substrates remains unresolved. In patients with sustained monomorphic ventricular tachycardia associated with a discrete akinetic area of the left ventricle, surgery offered as a last resort is less likely to produce favourable results and the decision of its use should therefore be taken early before unjustified drug trials go on.