Cor Vasa 2005, 46(3)

Management of post-infarction ventricular tachycardia by targeted surgical ablation using intraoperative mapping in sinus rhythm.

Jan Bytešník^2,*, Jan Pirk², Petr Peichl¹, Vlastimil Vančura¹, Josef Kautzner¹, Kateřina Lefflerová¹, Robert Čihák¹, Renata Krausová¹, Vladimír Vinduška², Zdeněk Hýža³, Jindřich Stupka³

¹ Klinika kardiologie

² Klinika kardiovaskulární chirurgie

³ Oddělení zdravotní techniky, Institut klinické a experimentální medicíny, Praha, Česká republika

Aim:
The aim of the study was to assess our own results in targeted surgical ablation of a potential arrhythmogenic substrate localized by intraoperative mapping in sinus rhythm in patients with sustained ventricular tachyarrhythmia (s-VTA) after myocardial infarction (MI).

Method:
A total of 77 consecutive patients (68 men, 9 women) with a mean age of 62.4 ± 8.5 years and left ventricular ejection fraction of 31.3 ± 8.8% developing, within one month or longer after a transmural MI, monomorphic or polymorphic sustained ventricular tachycardia (s-VT) and with inducible s-VTA by programmed ventricular pacing were operated. Sixty-nine (89.6%) of these patients underwent surgical myocardial revascularization while 31 (40.3%) had only epicardial cryoablation and 46 (59.7%) aneurysmectomy combined, in a proportion of patients, with subendocardial resection or endocardial cryoablation of the arrhythmogenic substrate, identified using fractionated, low-amplitude, and amplified local signals (ł 130 ms) during intraoperative mapping in sinus rhythm.

Results:
Five patients (6.5%) died in the perioperative (30-day) period; s-VT inducibility persisted postoperatively in 21 patients who had a cardioverter/defibrillator implanted. Hence, the acute success rate of the procedure was 51 out of the 72 surviving patients (70.8%). Epicardial cryoablation alone showed a lower success rate compared with surgical endocardial intervention (63.3% vs. 76.2%; p < 0.23). On longer follow-up (37.3 ± 23.2 months) 7 patients died (6 from heart failure, 1 from acute MI); however, there was no case of sudden death.
A long-term effect of the procedure, without recurrent clinical s-VTA, was obtained in 61 out of the original 72 survivors of acute postoperative period (84.7%).

Conclusions:
Targeted surgical ablation or isolation of arrhythmogenic substrate in patients with post-MI s-VT, guided by simplified intraoperative mapping of abnormal local signals in sinus rhythm, provides for relatively safe and effective treatment preventing recurrent s-VT in a substantial proportion of patients.

Keywords: Post-infarction ventricular tachycardia; Intraoperative mapping; Surgical ablation

Published: March 1, 2005  Show citation