Surgical treatment of tachyarrhythmias due to postinfarction left ventricular aneurysm with endoaneurysmorrhaphy and cryoablation.

OBJECTIVE: In this study, the efficacy of left ventricular (LV) endoaneurysmorrhaphy and cryoablation without intraoperative electrophysiologic mapping was evaluated in patients with postinfarction LV aneurysm and sustained ventricular tachycardia (VT). METHODS: A prospective study was performed on all patients operated with malignant VT in the presence of a resectable LV aneurysm between July 1990 and February 2001. RESULTS: The study included 31 patients, 20 men and 11 women, with a mean age of 65.5 years (47-84). Monomorphic, polymorphic VT or ventricular fibrillation was present in all patients prospectively, and VT was incessant in 11. Twenty-six patients had an anterior, four patients had an inferior and one patient a posterolateral myocardial wall infarction. All patients had a well-limited ventricular aneurysm. Ten patients had three, eight patients two and 13 patients had single vessel coronary artery disease. Mean preoperative ejection fraction was 34.8 +/- 14.5% (8-62) and mean end-diastolic volume index was 141.5 +/- 51.8 ml/m(2) (57-288). Six patients had mitral regurgitation grade III or IV. All patients underwent extensive cryoablation at the transition zone of scar and viable tissue and LV remodelling with prosthetic patch in 26 patients. Associated procedures were CABG in 19 patients (61%) and mitral valve reconstruction in six patients (19%). Postoperative electrophysiologic study (EPS) revealed freedom from VT induction in 25 patients and inducible VT in five patients. One patient had inducible polymorphic VT. Five patients received an implantable cardioverter defibrillator (ICD) and three patients had a permanent pacemaker implanted. After a mean follow-up of 30 +/- 27 months (6-132) there was one arrhythmia-related death. There was one early hospital readmission for clinical VT and no need for late ICD implantation. CONCLUSIONS: In patients suffering from ventricular arrhythmias in the presence of a complicated postinfarction LV aneurysm, combined 'blind' cryoablation and endoaneurysmorrhaphy offers excellent arrhythmia control and clinical and haemodynamic outcome.     

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.     

Late results of operation for ventricular tachycardia.

We have analyzed results in 54 consecutive patients with recurrent ventricular tachycardia and coronary artery disease in whom we used an aggressive surgical approach involving map-directed ventricular tachycardia ablation, scar excision and left ventricular remodeling, and coronary artery bypass grafting, as well as staged mitral valve replacement when necessary. We have previously shown age greater than 65 years to be an independent predictor of mortality and have excluded such patients from this series. Average age was 56 +/- 7 years. All patients had a previous myocardial infarction; 24% of the infarctions (13/54) were posterior in location. Symptoms included syncope or presyncope in 83% of the patients (45/54), angina in 54% (29/54), and congestive heart failure in 52% (28/54). Extensive coronary artery disease was found in 78% (42/54), and 89% (48/54) had serious compromise of left ventricular function (ejection fraction < 0.40; average ejection fraction, 0.28 +/- 0.12). Only 63% (34/54) appeared to have a resectable left ventricular aneurysm on the preoperative angiogram. Ablation techniques included endocardial excision in 82% (44/54), with the addition of cryoablation in 60% (32/54), and balloon electric shock ablation in 22% (12/54); coronary artery bypass grafting was performed in 85% (46/54). There were four hospital deaths (7%). The surgical cure rate (no inducible VT at postoperative electrophysiologic study was 72% (39/54). During follow-up (mean, 50 +/- 31 months) there have been six late deaths (1 sudden death, 1 stroke, 4 congestive heart failures with or without mitral regurgitation). Four patients with progressive congestive heart failure and serious mitral regurgitation have undergone repeat operation for mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of electrophysiologically guided operations for drug-resistant recurrent ventricular tachycardia and ventricular fibrillation due to coronary artery disease

Over a 39 month period, 143 patients with coronary artery disease had programmed stimulation (PES) for recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF). Twenty-two patients underwent operations. Ages ranged from 40 to 71 years; 20 of the 22 were men. All patients had coronary artery disease and 11 had left ventricular aneurysms. The mean ejection fraction was 31% (16% to 50%). Eighteen of the 22 patients underwent operations for drug-resistant ventricular arrhythmias (more than six different drugs plus drug combinations tested per patient). Nineteen patients had intraoperative mapping, endocardial resection, and/or an encircling endocardial ventriculotomy. Three patients with ischemia-related VT had coronary artery bypass (CABG) alone. The 30 day operative mortality was 14%. Thirteen of 19 (68%) operative survivors were effectively controlled with operation alone or a combination of operation and previously ineffective drug therapy. Of the six patients whose VT was inducible postoperatively, three have experienced episodes of sustained VT and one patient died suddenly. Three of these patients have the automatic implantable defibrillator. Operation guided by endocardial mapping is effective alone or in combination with drugs in this select group of patients. If the patients' VT was uninducible postoperatively with or without the addition of antiarrhythmic therapy, late deaths (3/19) were due to poor myocardial reserve and coronary artery disease, not the reemergence of sustained ventricular arrhythmias during a mean follow-up of 15 months.     

Dor operation for left ventricular aneurysm with sustained ventricular tachycardia

A 60-year-old woman was admitted to our hospital because of syncope attack due to sustained ventricular tachycardia (VT). She was treated medically after cardiopulmonary resuscitation. Coronary arteriography revealed a 99% stenosis of right coronary artery (posterior descending artery: # 4 PD), a 90% stenosis of left descending artery (# 6) and left akinetic aneurysm was demonstrated. The patient successfully underwent Dor operation with endocardial cryoablation. The postoperative course was uneventful and the recurrence of VT was never recognized clinically.     

Extensive endocardial resection for recurrent ventricular tachyarrhythmias

Twenty-two consecutive patients underwent elective map-guided extensive endocardial resection (EER) for recurrent ventricular tachyarrhythmias (VT) of whom 20 were male. The ages ranged from 43 to 74 years (mean 57). All arrhythmias were ischaemic in origin. The mean ejection fraction was 29%. The presenting arrhythmias were ventricular tachycardia in 14, ventricular fibrillation (VF) alone in 1 and ventricular tachycardia and VF in 7. Useful additional intraoperative mapping was obtained in 19 patients. Under cardioplegic arrest, the scarred left (22) and where indicated right (4) ventricular endocardium was extensively resected. Resection of scarred papillary muscles was avoided and where indicated, localised cryoablation was performed: 21/22 had concomitant aneurysmectomy and/or coronary artery bypass grafting. There was 1 (4.5%) operative death. All survivors (95.5%) underwent postoperative electrophysiological studies at around 1 week. None had inducible arrhythmias. There were 3 (13.5%) late cardiac deaths, all due to primary cardiac failure without recurrence of arrhythmia. Of 17 (77%) long-term survivors, 16 (94%) are VT-free on no anti-arrhythmic medication at a mean follow-up of 37.2 months. One developed a new arrhythmia at 1 year which is controlled on medication. EER offers a high rate of success in ablating VT in association with a low operative mortality and good prospect of VT-free long-term survival.     

Direct arrhythmia surgery in ventricular tachycardia: an experience with 18 consecutive patients

18 patients with ventricular tachycardia (VT) underwent direct arrhythmia surgery between 1984 and 1988. There were 8 patients with ischemic VT, and 10 with nonischemic VT. Operative technique consisted of ablative procedures of the arrhythmogenic area determined by pre- and intraoperative mapping. Induced VT was usually unstable and transient during operation, so that instantaneous multi-point mapping was necessary in almost cases. For VT originated in the left ventricle or interventricular septum, the earliest excitation point determined by the epicardial mapping did not always predict the endocardial arrhythmogenic focus. Pre- and/or intraoperative endocardial mapping was important in this regard. Cryocoagulation (-150 degrees C, 120 sec) was mainly used as an ablative procedure; for ischemic VT, endocardial resection was added, and in nonischemic VT originated in the right ventricular outflow tract, transmural resection was combined with the cryoablation. In performing surgery for nonischemic VT, care must have been taken to make transmural cryocoagulation because the arrhythmogenic focus could exist intramurally. There were no operative deaths. In one patient with nonischemic VT, reoperation was required. After a mean follow-up of 17 month, all the patients are free from sustained VT.     

Transatrial balloon technique for activation mapping during operations for recurrent ventricular tachycardia

Results of operations for recurrent ventricular tachycardia have improved since methods of mapping that allow a directed approach to the problem have been developed. With standard operative techniques (ventriculotomy and introduction of a hand-held probe or multiple electrode array), it has not always been possible to obtain satisfactory endocardial activation maps during the tachycardia. We have recently developed a new transatrial balloon approach that has greatly facilitated intraoperative mapping. This paper describes our total experience with the new approach and draws attention to details of the cardiopulmonary bypass technique and the surgical approach needed for safe balloon insertion across the mitral valve. We describe how correlation between position of target electrodes on the balloon and the internal geometry of the heart is achieved and discuss the choice and application of appropriate ablation techniques. In our series of 37 consecutive patients, 35% had a grade IV ventricle (ejection fraction less than 20%), 32% had a previous posterior infarct, 51% did not have a resectable aneurysm, and 54% had been receiving amiodarone within 1 month of the operation. These factors have been associated with poor operative results in other series. With the transatrial balloon technique, we were able to induce and map ventricular tachycardia in 100% of patients (average 2.6 +/- 1.3 morphologies per patient). Using a variety of ablation techniques (endocardial excision, cryoablation, or balloon electric shock ablation), we have achieved surgical control of the arrhythmias in 84% of patients with an operative mortality rate of 14%. We recommend transatrial balloon mapping as the procedure of choice for intraoperative identification of arrhythmogenic foci in patients with recurrent ventricular tachycardia.     

Factors affecting late survival after surgical remodeling of left ventricular aneurysms

OBJECTIVES: Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods. METHODS: From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch. RESULTS: Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04). CONCLUSIONS: Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.     

Operative risks and long-term results of operation for left ventricular aneurysm.

A review of 336 consecutive patients who underwent repair of left ventricular aneurysm from 1978 to 1989 disclosed that partial resection of the aneurysm and conventional closure of the ventriculotomy was performed in 281 patients, inverted T closure in 17, and endocardial patch in 38. These two latter techniques were developed in an attempt to restore normal left ventricular geometry. The operative mortality was 6.8% (23 patients). A stepwise logistic regression analysis of various preopeative clinical, hemodynamic, and angiographic variables revealed that left ventricular ejection fraction of 0.20 or less, age greater than 60 years, previous myocardial revascularization, lack of angina, and New York Heart Association functional class IV were independent predictors of operative mortality. The technique of repair was not a predictor of outcome, but when patients with poor left ventricular function were analyzed separately, the operative mortality was reduced from 12.5% to 6.5% when newer techniques were employed. Patients were followed up during a mean of 6.3 years. There have been 51 late deaths, 45 cardiac. Cox regression analysis indicated that poor left ventricular function and left main coronary artery stenosis were the only two predictors of late mortality. The actuarial survival at 10 years was 63% +/- 4%. Most patients (88%) are in New York Heart Association class I or II. These data indicate excellent long-term results after repair of left ventricular aneurysm. Newer techniques of repair are valuable in patients with poor left ventricular function.     

Mapping-guided focal cryoablation and endoaneurysmorrhaphy for a case of ischemic ventricular tachycardia with left ventricular aneurysm

A 74-year-old woman admitted with exertional dyspnea. Echocardiography revealed the giant left ventricular aneurysm. In the hospital course, she fell into sustained monomorphic ventricular tachycardia. Coronary angiogram showed complete obstruction of the LAD. Left ventricular ejection fraction was 20%. The origin of tachycardia seems to be at infero-apicallateral area of LV by electrophysiology study. Because of the failure of RF energy ablation, we planned mapping-guided cryoablation, CABG and endoaneurysmorrhaphy. To prevent air embolism and myocardial ischemic damage for long aortic cross clamp, intraoperative endocardial mapping was carried out on beating heart due to continuous normothermic coronary blood perfusion (300 ml/min) from the aortic root cannula under aortic clamping. Cold crystalloid cardioplegia changed into the root cannula after EPS, focal cryoablation (-100 degrees C) was performed 3 times on cardiac arrest. Sustained VT was not inducible in the following study. CABG and endoaneurysmorrhaphy was performed on repeated cardiac arrest during single aortic clamp. Postoperative course was uneventful, and she discharged 8 weeks after the operation.     

Surgical treatment of ventricular tachycardia in patients with arrhythmogenic right ventricular dysplasia and their long follow-up results

We have treated surgically the drug-refractory ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular dysplasia. The early and late results of the cryoablation were studied. We operated 8 patients. They showed 10 clinical VTs. A total of 21 VTs were detected (17 VTs during preoperative EPS, 4 VTs during intraoperative EPS). 19 VTs were operated: the origins of 15 VTs were determined by the intraoperative mapping, while those of 4 VTs were suspected by the preoperative EPS. During the follow-up time (mean 3.25 +/- 1.46 years), no patient died, VTs recurred in 2 patients and a new VT was seen in one patient. No recurrence was recognized in 12 VTs operated with the cryoablation applied from the endocardial side, but 4 out of 7 VTs recurred which were operated from the epicardial side. Cardiac arrest induced by aortic clamping didn't affected the efficacy of the cryoablation in the case of epicardial approach. CTR increased slightly postoperatively, from 49.9 +/- 4.4% to 53.3 +/- 5.3% at the 29.2 +/- 15.9 pom. No patients showed the signs of congestive heart failure postoperatively and required the medication except the patients with VT recurrence and a patient with the atrial flutter-fibrillation. In conclusion, even though this disease has the difficulty in the eradication of arrhythmia, VTs actually threatening the patient life at present could be cured by the cryoablation from the endocardial side.     

Sequential map-guided endocardial resection for ventricular tachycardia improves outcome.

OBJECTIVE: Surgery for ventricular tachycardias late after myocardial infarction is frequently associated with high mortality including sudden death, and arrhythmia recurrences. We examined our results of sequential map-guided endocardial resection at normothermia in patients with ventricular tachyarrhythmias late after myocardial infarction to assess the efficacy of this technique as well as the early and long-term outcome. METHODS: From 1995 to 1999, 22 patients underwent normothermic sequential map-guided endocardial resection for ventricular tachyarrhythmias late after myocardial infarction. Mean age was 61.2+/-6.5 years and left ventricular ejection fraction 32.5+/-8.7%. Adjunctive procedures included endoventricular patch repair of left ventricular aneurysm in 21 patients, coronary artery bypass grafting in 15 patients, and mitral valve replacement in one patient. Inducibility of ventricular tachycardia was evaluated postoperatively and patients were treated with sotalol or defibrillator implantation. RESULTS: The intraoperative number of inducible different ventricular tachycardia morphologies was 4.0+/-2.7. More than one mapping-resection sequence was needed in ten patients. In only one patient, sustained ventricular tachycardia was induced postoperatively, sotalol was not tolerated and a defibrillator was implanted. Five patients with inducible non-sustained ventricular tachycardia became non-inducible while on sotalol. There was one operative death (4.5%). During a median follow-up of 26 (1--62) months, there were neither cardiac deaths nor ventricular tachycardia recurrences. Two patients died from non-cardiac causes. Cumulative probability of survival at 5 years was 0.83+/-0.09. CONCLUSIONS: Sequential map-guided endocardial resection at normothermia was associated with low operative mortality and low postoperative inducibility of sustained ventricular tachycardia. The selected therapeutic approach resulted in freedom of arrhythmia recurrence and cardiac mortality including sudden death, during long-term follow-up.     

Transannular cryoablation of ventricular tachycardia. Surgical technique and results

Intraoperative mapping and cryoablation of ventricular tachycardia was achieved without ventriculotomy in seven patients, who are a subgroup of the 80 patients undergoing map-directed ablation of ventricular tachycardia over a 9-year period. There were four male and three female patients. Their mean age was 53.6 +/- 24.1 years. Coronary artery disease was present in five patients, and two patients had idiopathic ventricular tachycardia. The mean preoperative ejection fraction was 42.4% +/- 13.6%. The mean number of ventricular tachycardia morphologies was 1.7 (range 1 to 3). Epicardial mapping was obtained intraoperatively in all seven patients and endocardial data in five of seven patients (71.4%). There were no hospital deaths and no early or late spontaneous recurrence of clinical monomorphic ventricular tachycardia. Nonclinical monomorphic ventricular tachycardia was inducible in two patients postoperatively and both were treated with procainamide. Death occurred late after operation in two patients: One death was related to recurrent nonclinical VT at 8 months and one at 3 months was due to carcinoma of the stomach. These results suggest that the transannular approach is feasible in selected cases, especially when computerized mapping systems with endocardial balloon electrode arrays can be used.     

Surgical ablation of post-infarction ventricular tachycardia guided by mapping in sinus rhythm: long term results.

OBJECTIVE: Some patients after myocardial infarction have an increased risk of malignant ventricular tachyarrhythmias (VTA) or sudden cardiac death. The aim of the study was to evaluate long-term results of surgical ablation of an arrhythmogenic substrate guided by simplified intraoperative mapping of pathological ventricular electrograms during sinus rhythm. METHODS: The study population consisted of 77 patients (9 women; mean age 62.4+/-8.5 years) with previous Q-wave myocardial infarction and at least one documented episode of sustained VT/VF more than one month after the last infarction. The left ventricular ejection fraction was 31.3+/-8.8%. All but eight patients had clinical indication for concomitant coronary artery bypass surgery. All underwent preoperative electrophysiologic study. Intraoperative epicardial and endocardial mapping during sinus rhythm was performed using a multielectrode with 16 bipolar electrodes in combination with a multichannel recording system. Myocardial regions revealing fractionated, low amplitude signals lasting > or =130 ms were surgically excised or cryoablated. All surviving patients were restudied within one to two weeks after surgery using identical programmed electrical stimulation protocol. RESULTS: Five (6.5%) patients died in the perioperative (30-days) period. In the remaining cohort, inducibility of any sustained VTA after surgical procedure was observed in 21 subjects (29.2%). An implantable cardioverter-defibrillator (ICD) was implanted in these patients. Recurrence of sustained VTA was documented during follow-up period in two patients who were noninducible after the surgery (at the month 10 and 22, respectively), and both received ICD as well. No patient died of sudden cardiac death. In 14 ICD patients, no significant VTA was documented during the mean follow-up of 37.3+/-23.2 months. Altogether, 61 from the 72 patients surviving the surgery (84.7%) remained free of spontaneous recurrences of VTA during the follow-up. CONCLUSIONS: Surgical ablation of an arrhythmogenic substrate guided by simplified intraoperative mapping in normothermic heart during sinus rhythm appears to be both safe and efficacious procedure that prevents recurrences of VTA in a substantial proportion of patients.     

Left ventricular performance before and after left ventriculotomy and removal of a left ventricular aneurysm

The effects of left ventriculotomy on left ventricular performance were studied in seven patients with ventricular tachyarrhythmia (VT) and nine patients with left ventricular aneurysm (LVA). Hemodynamic and left ventriculographic findings were evaluated before and after operations. In VT the non-contracting areas, measured at end-diastole, as mean 10.8 +/- 7.1% of the left ventricular internal surface area. There was no significant fall in left ventricular ejection fractions (EF), cardiac indexes (CI) and left ventricular end-diastolic volume indexes (LVEDVI) after left ventriculotomy. In LVA, the non-contracting areas decreased from 31.0 +/- 7.4% to 13.7 +/- 13.5% (p less than 0.01) in association with a reflex decrease in LVEDVI from 117 +/- 31.8 ml/m2 to 90.4 +/- 24.7 ml/m2 (p less than 0.05). EF increased from 40.8 +/- 7.00% to 54.6 +/- 10.7% (p less than 0.01). There was no significant change in CI and left ventricular stroke volume index after left ventricular aneurysmectomy. The observations indicate that left ventriculotomy of limited size is an acceptable and a safety approach to the ventricular tachyarrhythmias and another cardiac operations.     

The incidence and outcome of ventricular arrhythmias after noncardiac thoracic surgery

Atrial arrhythmias are common after thoracic surgery, but the incidence and significance of ventricular arrhythmias early after such surgery are not well established. Our goal was to determine the incidence and outcome of this complication from a continuing prospective database in 412 patients who had lobectomy (n = 243) or pneumonectomy (n = 169) and were continuously monitored with Holter recorders for 72-96 h postoperatively. The primary end point of the study was the occurrence of ventricular tachycardia (VT) defined as three or more consecutive wide complexes. Sixty-one of 412 patients (15%) developed 1 or more episode of VT. There were no episodes of sustained (>30 s) VT and no patient required treatment for hemodynamic compromise associated with any VT episode. Patients with VT had a more frequent incidence of a preoperative left bundle branch block (P = 0.01) but did not differ in other clinical characteristics, operative data, or core temperature on arrival to the postanesthesia care unit, when compared with those without VT. Patients who developed VT had significantly more atrial premature contractions (P < 0.001), ventricular premature contractions (P < 0.001), ventricular couplets (P < 0.001), and postoperative atrial fibrillation, 21 of 61 (34%) versus 58 of 351 (17%), P = 0.001, than those without VT, respectively. Multivariate logistic regression analysis revealed that only postoperative atrial fibrillation occurrence was independently associated with VT (relative risk 2.6, 95% confidence intervals 1.4 to 4.8, P = 0.002). We conclude that nonsustained VT after noncardiac thoracic surgery occurs frequently but is not associated with poor outcome. The strong association of atrial and ventricular arrhythmogenesis with VT suggests that vagal withdrawal and/or adrenergic hyperactivity may have a role in precipitating these events in the early postoperative period. IMPLICATIONS: In 412 patients, we determined that the incidence of nonsustained ventricular tachycardia after major thoracic surgery is 15% and is not associated with poor outcome.     

New-onset sustained ventricular tachycardia and fibrillation early after cardiac operations

BACKGROUND: Malignant ventricular tachyarrhythmia early after cardiac surgery is an uncommon arrhythmic complication but has a negative impact on mortality. The purpose of this study was to evaluate the incidence of new-onset sustained postoperative ventricular tachycardia-ventricular fibrillation and to identify risk factors for the dysrhythmia. METHODS: Demographic, clinical, operative, and postoperative data, including a variable of postoperative ventricular tachycardia, were prospectively obtained from 4748 patients undergoing nonemergency coronary artery bypass graft and(or) valve replacement with no history of sustained ventricular tachycardia or sudden death. A detailed analysis was performed to define the risk factors for the ventricular tachycardia and the prognostic impact of the arrhythmia on 30-day mortality was evaluated. RESULTS: Forty-five patients (0.95%) had sustained ventricular tachycardia or ventricular fibrillation and the initial episode occurred 3.9 +/- 5.2 days (mean +/- standard deviation) after surgery. By multivariate analysis, female sex (odds ratio, 1.982), left ventricular ejection fraction (< 35%: > 50%, 4.771), the presence of pulmonary hypertension (3.066), the presence of systemic hypertension (2.391), and pump time (per 10 minutes, 1.085) were independently associated with the dysrhythmias. Early mortality of patients with the arrhythmia was 28.9%, strikingly higher than that of patients without ventricular tachycardia/ventricular fibrillation (1.9%). CONCLUSIONS: Left ventricular ejection fraction is the strongest risk factor for new-onset postoperative sustained ventricular tachycardia-ventricular fibrillation; female sex, pump time, pulmonary and systemic hypertension are independent predictors of the dysrhythmias; the arrhythmia is associated with increased 30-day mortality after cardiac surgery.     

Concomitant left ventricular assist device placement and cryoablation for treatment of ventricular tachyarrhythmias associated with heart failure

Refractory ventricular tachyarrythmias (VTs) are potentially life-threatening rhythms in patients with cardiomyopathies, particularly when they result in hemodynamic instability. Here we report two cases of patients with intractable ventricular tachyarrythmias that were unresponsive to anti-arrhythmic medications and repeated catheter ablation, and for whom concomitant cryoablation and left ventricular assist device implantation was successfully performed. Both patients tolerated the procedure well with no complications and were free from ventricular tachyarrythmias postoperatively. Concomitant surgical ventricular ablation at the time of left ventricular assist device surgery may be a reasonable approach for this subset of patients as it provides excellent visualization and the ability to ablate both epicardial and endocardial sites.     

Pulmonary autografts in patients with severe left ventricular dysfunction

BACKGROUND: Performing a Ross operation in patients with severe left ventricular dysfunction is controversial. The objective in this retrospective study was to determine the outcome of 15 patients with aortic valve disease (11 had aortic insufficiency and 4 had aortic insufficiency and aortic stenosis) associated with reduced left ventricular function (ejection fraction < 40%) treated with a pulmonary autograft. METHODS: We identified 15 patients with severe left ventricular dysfunction from 226 consecutive pulmonary autograft procedures done between age 18 and 50 years from 1986 to 2001. Patients had documented preoperative ejection fraction less than 40% and were in New York Heart Association class III or IV. Preoperative ejection fraction ranged from 18% to 37% (mean, 31% +/- 6.5%). Transthoracic echocardiograms obtained preoperatively and at 1-week, 6-month, and 1- and 2-year intervals were reviewed. Records were evaluated for survival, clinical status, left ventricular function, and valve function. RESULTS: There were no operative deaths, late deaths, or reoperations. All patients had follow-up examinations within the past year and are clinically well (67% > 2 years follow-up). Ten of 15 patients (67%) had substantially improved ventricular function (> 20% increase). The average ejection fraction increased from 31% +/- 7% preoperatively to 51% +/- 11% at 2 years, and the increase is significant from 1 week on (p < 0.02). Average left ventricular mass index decreased by 41% at 6 months (n = 10; p = 0.009) and by 44% at 2 years (n = 9; p = 0.02). Mean Z values for left ventricular mass decreased from 7.6 to 3.6 after more than 2 years (p = 0.007). CONCLUSIONS: The Ross operation is an appropriate option in adults age 50 or younger in the presence of decreased left ventricular ejection fraction. Neither operative mortality nor postoperative sequelae were identified in our subset of patients. Excellent survival and ventricular recovery are predicted.