Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND)

BACKGROUND

Riluzole has been approved for treatment of patients with amyotrophic lateral sclerosis in many countries but not all. Questions persist about its clinical utility because of high cost, modest efficacy and concern over adverse effects.

OBJECTIVES

To examine the efficacy of riluzole in prolonging survival, and in delaying the use of surrogates (tracheostomy and mechanical ventilation) to sustain survival.

SEARCH STRATEGY

Search of the Cochrane Neuromuscular Disease Group Register for randomized trials and enquiry from authors of trials, Aventis (manufacturer of riluzole) and other experts in the field. The most recent search was May, 2001 SELECTION CRITERIA: Types of studies: randomized trials

TYPES OF PARTICIPANTS

adults with a diagnosis of amyotrophic lateral sclerosis Types of interventions: treatment with riluzole or placebo Types of outcome measures: Primary: pooled hazard ratio of tracheostomy-free survival over all time points with riluzole 100 mg. Secondary: per cent mortality as a function of time with riluzole 100 mg and other doses of riluzole; neurologic function, quality of life, muscle strength and adverse events.

DATA COLLECTION AND ANALYSIS

We identified four eligible randomized trials. Each reviewer graded them for methodological quality. Data extraction was performed by a single reviewer and checked by two others. We obtained some missing data from investigators and regulatory agencies. We performed meta-analyses with Review Manager 4.1 software using a fixed effects model. A test of drug efficacy was based on the Parmar pooled hazard ratio.

MAIN RESULTS

The three trials examining tracheostomy-free survival included a total of 876 riluzole treated patients and 406 placebo treated patients. The data for tracheostomy-free survival was not available from the fourth trial. The methodological quality was acceptable and the three trials were easily comparable, although one trial included older patients in more advanced stages of amyotrophic lateral sclerosis. Riluzole 100 mg per day provided a benefit for the homogeneous group of patients in the first two trials (p=0.039, hazard ratio 0.80, 95% confidence interval 0.64 to 0.99) and there was no evidence of heterogeneity (p=0.33). When the third trial (which included older and more seriously affected patients) is added, there is evidence of heterogeneity (p<0.0001) and the random effects model, which takes this into account results in the overall treatment effect estimate falling just short of significance (p=0.056, hazard ratio 0.84, 95% confidence interval 0.70 to 1.01). This represents a 9% gain in the probability of surviving one year (57% in the placebo and 66% in the riluzole group). In secondary analyses of survival at separate time points, there was a significant survival advantage with riluzole 100 mg at six, nine, 12 and 15 months, but not at three or 18 months. There was a small beneficial effect on both bulbar and limb function, but not on muscle strength. There were no data on quality of life, but patients treated with riluzole remained in a more moderately affected health state significantly longer than placebo-treated patients (weighted mean difference 35.5 days, 95% confidence interval 5.9 to 65.0). A threefold increase in serum alanine transferase was more frequent in riluzole treated patients than controls (weighted mean difference 2.69, 95% confidence interval 1.65 to 4.38).

REVIEWER'S CONCLUSIONS

Riluzole 100 mg daily is reasonably safe and probably prolongs survival by about two months in patients with amyotrophic lateral sclerosis. More studies are needed, especially to clarify its effect in older patients (over 75 years), and those with more advanced disease.

Recombinant human insulin-like growth factor I (rhIGF-I) for amyotrophic lateral sclerosis/motor neuron disease

BACKGROUND

Trophic factors, including recombinant human insulin-like growth factor I have been postulated as possible disease modifying therapies for amyotrophic lateral sclerosis. Randomised clinical trials of recombinant human insulin-like growth factor I in amyotrophic lateral sclerosis to date have yielded conflicting results.

OBJECTIVES

The main objective of this review was to examine the efficacy of recombinant human insulin-like growth factor I in amyotrophic lateral sclerosis. Occurrence of adverse events has also been reviewed.

SEARCH STRATEGY

A search was carried out using the Cochrane Neuromuscular Disease Group register for randomised clinical trials of recombinant human insulin-like growth factor I in amyotrophic lateral sclerosis. Enquiries were also made of authors of randomised clinical trials as well as the manufacturers of recombinant human insulin-like growth factor I regarding any other randomised clinical trials which had not yet been published.

SELECTION CRITERIA

Types of studies: all randomised controlled clinical trials involving recombinant human insulin-like growth factor I treatment of amyotrophic lateral sclerosis.

TYPES OF PARTICIPANTS

Adults with a clinical diagnosis of definite or probable amyotrophic lateral sclerosis according to the El Escorial Criteria. Types of interventions: Treatment with recombinant human insulin-like growth factor I or placebo. Types of outcome measures: Primary: Change in Appel Amyotrophic Lateral Sclerosis Rating Scale (AALSRS) total score with 0.1mg/kg/day of recombinant human insulin-like growth factor I after nine months treatment. Secondary: Change in AALSRS with recombinant human insulin like growth factor I 0.1mg/kg/day and 0.05mg/kg/day at 1, 2, 3, 4, 5, 6, 7, 8, 9 months, change in quality of life (Sickness Impact Profile scale), survival and adverse events.

DATA COLLECTION AND ANALYSIS

We identified two randomised clinical trials. Each reviewer graded them for methodological quality. Data were extracted and entered by the lead reviewer and checked by the other two. Some missing data had to be regenerated by calculations based on ruler measurements of data presented in published graphs.

MAIN RESULTS

The primary outcome measure was change in disease progression as determined by the Appel ALS Rating Scale total score with 0.1 mg/kg/day of recombinant human insulin-like growth factor I subcutaneously after nine months treatment. The level of significance was lower in the European trial which compared 59 patients on placebo with 124 on insulin-like growth factor I 0.1 mg/kg/day (weighted mean difference -3.30, 95%CI -8.68 to 2.08) than in the North American trial which compared 90 patients on placebo with 89 on recombinant human insulin-like growth factor I 0.05 mg/kg/day 89 patients and 87 patients on 0.1mg/kg/day (weighted mean difference -6.00, 95%CI -10.99 to -1.01). The combined analysis from both randomised clinical trials showed a weighted mean difference of -4.75 (95% CI -8.41 to -1.09) favouring the treated group. The secondary outcome measures showed similar trends favouring recombinant human insulin-like growth factor I but these did not reach significance at the five per cent level. Similarly the data with the 0.05mg/kg/day dose showed trends favouring recombinant human insulin-like growth factor I at all time points but did not reach significance at the five per cent level at any point. Evaluation of adverse events showed an increased risk of injection site reactions/inflammation with recombinant human insulin-like growth factor I (relative risk 2.53, 95% CI 1.40 to 4.59). The drug was otherwise safe and well tolerated.

REVIEWER'S CONCLUSIONS

Recombinant human insulin-like growth factor I may be modestly effective but the evidence currently available is insufficient for a definitive assessment. Further randomised clinical trials need to be done.

Patients' health-related quality of life and utilities associated with different stages of amyotrophic lateral sclerosis

OBJECTIVES

Amyotrophic lateral sclerosis (ALS) is a devastating disease that has serious consequences in terms of impairments and disabilities, which are expected to impact on health-related quality of life (HRQL). The aim of the present study was to assess self-reported health status and HRQL, as well as patients' own valuation of their present health state in a sample of patients with different levels of severity of ALS.

METHODS

Structured interviews were conducted with 77 patients with different levels of disease severity. Patients completed a disease-specific health status measure (ALSAQ-40), a generic health status measure (EuroQol EQ-5D), visual analogue scale (VAS) rating of current health and a standard gamble (SG) exercise to provide health state utilities for their own health state.

RESULTS

The results from the ALSAQ-40 and EQ-5D descriptive system indicate that patients' HRQL decreases systematically with increasing severity of disease. Patients' mean VAS rating of their own health ranged from 0.74 for stage 1 (early) disease severity, to 0.37 for stage 4 (late stage) disease severity. Utilities elicited via SG were systematically higher than VAS scores and ranged from a mean of 0.79 for stage 1 disease severity to a mean of 0.45 for stage 4 disease severity.

Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome

OBJECTIVE

Bronchogenic carcinoma in close proximity to or involving the carina remains a challenging problem for thoracic surgeons. The operative procedures to allow complete resection are technically demanding and can be associated with significant morbidity and mortality. Little is known about long-term survival data to guide therapy in these patients.

METHODS

We conducted a single-institution retrospective review.

RESULTS

We have performed 60 carinal resections for bronchogenic carcinoma: 18 isolated carinal resections for tumor confined to the carinal or proximal main stem bronchus; 35 carinal pneumonectomies; 5 carinal plus lobar resections, and 2 carinal resections for stump recurrence after prior pneumonectomy. Thirteen patients (22%) had a history of lung or airway surgery. The overall operative mortality was 15%, improved from the first half of the series (20%) to the second half (10%), and varied according to the type of resection performed. Adult respiratory distress syndrome was responsible for 5 early deaths, and all late deaths were related to anastomotic complications. In 34 patients, all lymph nodes were negative for metastatic disease; 15 patients had positive N1 nodes, and 11 patients had positive N2/N3 nodes. Complete follow-up was accomplished in 90%, with a mean follow-up of 59 months. The overall 5-year survival including operative mortality was 42%, with 19 absolute 5-year survivors. Survival was highest after isolated carinal resection (51%). Lymph node involvement had a strong influence on survival: patients without nodal involvement had a 5-year survival of 51%, compared with 32% for patients with N1 disease and 12% for those with N2/N3 disease.

CONCLUSIONS

This constitutes one of the largest single-institution reports on carinal resection for bronchogenic carcinoma involving the carina. Morbidity and mortality rates are acceptable. The overall survival including operative mortality is 42%. Positive N2/N3 lymph nodes may be a contraindication to surgery because of poor prognosis.

Guidelines in motor neurone disease (MND)/amyotrophic lateral sclerosis (ALS)--from diagnosis to patient care

This paper reviews the scope of current guidelines in motor neurone disease (MND)/amyotrophic lateral sclerosis (ALS) and examines issues which have arisen in the preparation of these documents. The review concludes with an evaluation of the impact of the guidelines which have been produced to date and looks towards potential future developments in this area.

Amyotrophic lateral sclerosis: toxins and environment

The role of environmental influences in the aetiopathogenesis of amyotrophic lateral sclerosis (ALS) has exercised minds since the 19th century. Despite strong hunches that environmental agents might be implicated in the causation of ALS, research seeking more objective evidence has generally yielded results which have been confusing and difficult to understand in terms of a unitary aetiological hypothesis. This review attempts to draw this evidence together in the context of a semi-systematic review of the literature. Potential physical influences are described as well as the better known chemical factors. The interface with recent advances in molecular genetics is reviewed as well as foci of ALS variants as they occur in localized areas in various parts of the world. There is a discussion of large and small area geographical clustering and the review concludes by presenting a general view of the possible significance of these--at times--confusing pointers in the context of other current theories of the aetiology of ALS.

Clinical experience with carinal resection

OBJECTIVE

Pathologic processes that involve the carina pose a tremendous challenge to thoracic surgeons. Although techniques have been developed to allow primary resection and reconstruction, few institutions have accumulated sufficient experience to allow meaningful conclusions about the indications and the morbidity and mortality rates for this type of surgery.

METHODS

Since 1962, 135 patients have undergone 143 carinal resections (134 primary resection, 9 re-resection) at our institution. Indications for carinal resection included bronchogenic cancer (58 patients), other airway neoplasms (60 patients), and benign or inflammatory strictures (16 patients). Thirty-seven patients (28%) had a history of prior lung or airway surgery not involving the carina. Carinal resection without pulmonary resection was accomplished in 52 patients; 57 patients had carinal pneumonectomy (44 right, 13 left); 14 patients had carinal plus lobar resection, and 11 patients had carinal resection after pneumonectomy (9 left, 2 right). There were 15 different modes of reconstruction, based on the type and extent of resection. Techniques were used to reduce anastomotic tension.

RESULTS

The operative mortality rate in the 134 patients after primary carinal resection was 12.7%. Adult respiratory distress syndrome was responsible for 9 early deaths. Predominant predictors of operative death included postoperative mechanical ventilation (P =.001), length of resected airway (P =.03), and development of anastomotic complications (P =.04). Mortality rates varied by the type of procedure and the indication for resection. Left carinal pneumonectomy was associated with a high operative mortality rate (31%). Complications were noted in 52 patients (39%), including atrial arrhythmias (20 patients) and pneumonia (11 patients). Anastomotic complications, both early and late, were seen in a total of 23 patients (17%) and resulted in death or surgical reintervention in 21 patients (91%). The operative mortality rate for carinal re-resection was 11.1%.

CONCLUSIONS

Carinal resection with primary reconstruction may be accomplished with acceptable mortality rates, but the underlying pathologic process and chance for long-term survival must be carefully considered before the operation is recommended, especially in the case of left carinal pneumonectomy. Anastomotic complications exact a heavy toll on involved patients. Careful patient selection and meticulous anesthetic and surgical technique remain the key to minimizing morbidity and mortality rates.

Geographical epidemiology of residence of patients with motor neuron disease in Lancashire and south Cumbria

OBJECTIVES

To seek objective evidence for geographical clustering of places of residence of patients with motor neuron disease (MND).

METHODS

A complete residential history from birth to onset of disease was obtained from a cohort of 130 patients with MND from Lancashire and south Cumbria presenting to the Department of Neurology in Preston between 1 January 1989 and 31 December 1993. These data were compared with population based reference data from the 1991 UK Census.

RESULTS

Some areal units showed a greater, others a lesser, number of MND patient residences than expected. The results suggest that the background population incidence of MND is relatively low and that the overall incidence figures previously quoted have been skewed upwards by areas in which the incidence of MND is relatively increased. These findings were further tested by Poisson modelling. The Poisson model provided a poor fit for the data at postcode district and sector levels confirming that patients with MND were significantly more likely to have lived in some areas than others after allowing for variation in population of the different areal units and for variation in duration of residence.

CONCLUSIONS

These findings reinforce the results of previous work, much of which has been qualitative rather than quantitative. The results presented here suggest a low background incidence of MND in the context of generally quoted overall incidence figures. This low background incidence is, however, skewed upwards by some areal units with a relatively high incidence, thus achieving overall incidence rates comparable with generally quoted figures. We conclude that there is prima facie evidence of spatial patterns in the distribution of places of residence of patients with MND. Further examination of occupational and environmental factors in the lives of the patients with MND is required to obtain a better understanding of the importance of these findings.

Mighty morphing spatial solitons and bullets

We give what we believe to be the first closed-form exact expression for the dynamic evolution of nonstationary beams of arbitrary intensity and width propagating in a uniform nonlinear medium and in both two and three dimensions. This shows that periodic and quasi-periodic (nonradiating) beams can exist in a non-Kerr nonlinear medium. The Schrödinger equation is solved for Gaussian beams in a saturable medium. For one critical (initial) beam width, the Gaussian is a stable stationary soliton or bullet, independent of its intensity; otherwise, it breathes. New quasi-periodic beams (mighty morphing solitons) and bullets (mighty morphs) of elliptical cross section also exist whose ellipticity changes with propagation.

Acute angle-closure glaucoma associated with intranasal cocaine abuse

PURPOSE

We report a case of acute angle-closure glaucoma associated with ipsilateral intranasal cocaine abuse.

METHODS

We examined and treated a 55-year-old white man who developed primary angle-closure glaucoma in the right eye shortly after intranasal cocaine abuse.

RESULTS

The patient was successfully treated with Nd:YAG laser peripheral iridotomy on the right eye.

CONCLUSION

Cocaine causes mydriasis and can induce angle closure in predisposed individuals.

Patient health questionnaire. Using a patient-focused assessment tool

A patient health questionnaire was developed for use in family practice to help identify lifestyle risk factors, assess health care needs, and better understand patients. This article discusses the questionnaire's development and practical application.

Studies on cellular free radical protection mechanisms in the anterior horn from patients with amyotrophic lateral sclerosis

There have been no reports of changes in free radical inactivating enzymes in the anterior horn of the spinal cord in ALS despite great interest in the possibility that free radicals might be important in the aetiology of the disease. In this study we have measured copper/zinc superoxide dismutase (Cu/ZnSOD), manganese superoxide dismutase (MnSOD) and glutathione peroxidase (GSHPX) activities in anterior horn tissue obtained from patients with ALS and from controls. Total SOD activity was no different in the anterior horn of ALS cases compared to controls, but Cu/ZnSOD activity was reduced, and that of MnSOD increased, at thoracic cord level only. No detectable activity of GSHPX or cytochrome P450 (unpublished data) was found. These latter negative findings are important because they suggest that generation of free radicals from exogenous chemicals is not important in ALS and further that the neurone (as compared to other cell types) is poorly protected against the toxicity of hydrogen peroxide.

Diagnostic issues in a family with late onset type 2 neurofibromatosis

We report a family with type 2 neurofibromatosis and late onset tumours. Five members of this family have developed hearing loss late in life, two of whom have only been shown to have the diagnosis in their seventies, and three other obligate gene carriers died undiagnosed at 64, 72, and 78 years of age. A missense mutation at the C-terminal end of the NF2 protein has been identified in this family and segregates with disease. The use of highly polymorphic markers for predictive testing is also shown. There appears to be an autosomal dominant form of spinocerebellar degeneration which is segregating separately to NF2 in this family, which created a diagnostic dilemma.

Multislab three-dimensional T2-weighted fast spin-echo imaging of the hippocampus: sequence optimization

Three-dimensional (3D) fast spin-echo (FSE) imaging can produce contiguous thin sections for high-quality multiplanar reconstructions. Such reformatted images may be useful in the evaluation of three-dimensionally complex, curvilinear anatomic structures such as the hippocampus. The authors describe a 3D FSE protocol for T2-weighted imaging of the hippocampus. The protocol uses an overlapping-multiple-slab imaging strategy to decrease imaging times and a modified refocusing radio-frequency pulse train to improve the reformatted images. The authors describe their parameter optimization, discuss the benefits and limitations of the new sequence, and present representative images of healthy volunteers.

Alteration of superoxide dismutase activity in the anterior horn in motoneuron disease patients

Studies on anterior horn dissected from MND patients have demonstrated that MnSOD activity is increased when expressed as a percentage of total SOD activity when compared to controls. Total SOD activity (mean +/- SD) in controls = 414 +/- 105 U mg-1 tissue and in MND patients = 373 +/- 115 U mg-1 tissue, whereas CuZnSOD activity was higher in controls (290 +/- 91 U mg-1 tissue) than in MND patients (197 +/- 81 U mg-1 tissue). The reduction in CuZnSOD was compensated for by a concomitant elevation of MnSOD activity (control = 123 +/- 40.5 U mg-1 tissue, MND patients = 175 +/- 47 U mg-1 tissue). These data not only show an important deficit in anterior horn cell body protection against free radical-mediated cell damage, but are also are the first measurements of SOD isoenzymes in anterior horn neurones.

Preliminary results of proton magnetic resonance spectroscopy in motor neurone disease (amytrophic lateral sclerosis)

Possible changes in brain metabolites in motor neurone disease/amytrophic lateral sclerosis (MND/ALS) were investigated using 1H magnetic resonance spectroscopy (MRS). A series of normal, healthy volunteer controls and MND patients have been studied using a spin echo (SE) 135 ms sequence, acquiring spectra from the region of the motor cortex. A further limited series of studies have been made for similar groups of volunteers and MND patients using a STEAM 20 ms sequence (stimulated echo). Analysis of the SE 135 ms spectra indicates there are statistically significant differences in the ratios of N-acetyl-aspartate to creatine and N-acetyl-aspartate to choline between controls and MND patients. Furthermore, metabolites identified using the STEAM 20 ms may be of great importance in the investigations of free radical mediated mechanisms, which have been postulated as being important contributors to the disease process. Preliminary results indicate that 1H MRS may provide important data to help understand the disease processes in MND and it could form a useful method for monitoring the effects of future trial treatment regimens.

Norepinephrine infusion following cardiopulmonary bypass: effect of infusion site

The placement of left atrial catheters following cardiopulmonary bypass (CPB) allows accurate monitoring of left ventricular filling pressures, as well as access for the infusion of vasoactive drugs. While the left atrial administration of norepinephrine (NE) is thought to provide higher systemic arterial NE levels while minimizing any pulmonary vasoconstriction, no study critically compares central venous and left atrial NE infusion following cardiopulmonary bypass. A canine model was used to compare central venous and left atrial NE infusion at three dosages (0.2, 0.4, and 0.6 microgram/kg/min) both prior to CPB and following 2 hr of hypothermic CPB at 27 degrees C. Prior to CPB, there was no difference in the hemodynamic efficacy of central venous and left atrial NE infusion at any dosage. The pulmonary circulation metabolized 16-29% of circulating NE. Only at the 0.2 microgram/kg/min dose was there a difference in the arterial NE level between central venous (3474 +/- 486 pg/ml) and left atrial (5504 +/- 751 pg/ml, P = 0.019) NE administration. Above this dose, no difference in the arterial NE level was identified. Following 2 hr of CPB, the pulmonary endothelium metabolized a significantly higher percentage of circulating NE (35-42%). Despite this increased extent of pulmonary metabolism, there was no difference in the hemodynamic efficacy or the resulting arterial NE level of central venous and left atrial NE infusion at a given dose. In conclusion, the results demonstrate: (1) increased pulmonary NE uptake following CPB, and (2) no difference in hemodynamic efficacy between central venous and left atrial NE infusion over a wide range of three doses in a model with normal lungs.

Prevention of postoperative pericardial adhesions with a hyaluronic acid coating solution. Experimental safety and efficacy studies

Postoperative pericardial adhesions complicate reoperative cardiac procedures. Topical application of solutions containing hyaluronic acid have been shown to reduce adhesions after abdominal and orthopedic surgery. The mechanism by which hyaluronic acid solutions prevent adhesion formation is unknown but may be due to a cytoprotective effect on mesothelial surfaces, which would limit intraoperative injury. In this study, we tested the efficacy and safety of hyaluronic acid coating solutions for the prevention of postoperative intrapericardial adhesion formation. Eighteen mongrel dogs underwent median sternotomy and pericardiotomy followed by a standardized 2-hour protocol of forced warm air desiccation and abrasion of the pericardial and epicardial surfaces. Group 1 (n = 6) served as untreated control animals. Group 2 (n = 6) received topical administration of 0.4% hyaluronic acid in phosphate-buffered saline solution at the time of pericardiotomy, at 20-minute intervals during the desiccation/abrasion protocol, and at pericardial closure. The total test dose was less than 1% of the circulating blood volume. Group 3 (n = 6) served as a vehicle control, receiving phosphate-buffered saline solution as a topical agent in a fashion identical to that used in group 2. At resternotomy 8 weeks after the initial operation, the intrapericardial adhesions were graded on a 0 to 4 severity scale at seven different areas covering the ventricular, atrial, and great vessel surfaces. In both the untreated control (group 1, mean score 3.2 +/- 0.4) and vehicle control (group 3, mean score 3.3 +/- 0.2) animals, dense adhesions were encountered. In contrast, animals treated with the hyaluronic acid solution (group 2, mean score 0.8 +/- 0.3) characteristically had no adhesions or filmy, transparent adhesions graded significantly less severe than either the untreated control (group 2 versus group 1, p < 0.001) or vehicle control (group 2 versus group 3, p < 0.001) animals. In separate experiments, six baboons were infused with 0.4% hyaluronic acid in phosphate-buffered saline solution in volumes equivalent to 2.5%, 5%, and 10% of the measured circulating blood volume. The 2.5% and 5% infusions had no effect on the parameters measured; infusion of the 10% volume produced transient hemodynamic, coagulation, and gas exchange abnormalities. Hyaluronic acid solutions are efficacious in the prevention of pericardial adhesions in this model, and they appear safe in doses five times the amount needed to prevent adhesions. Further studies investigating the mechanism by which these solutions prevent adhesions, their optimal dose and method of application, and documentation of their safe use in humans are warranted.

Operation for recurrent ventricular tachycardia. Predictors of short- and long-term efficacy

The success of ventricular operation in ablating drug-refractory ventricular tachycardia secondary to ischemic heart disease varies with surgical technique, the presence of certain identified risk factors, and patient selection biases. Forty-eight patients with drug-refractory ventricular tachycardia secondary to ischemic heart disease underwent directed ventricular operation. All patients had previous myocardial infarction, and 46 of 48 patients had a left-ventricular aneurysm. Mapping was done in 81% of patients. Patients underwent a combination of subendocardial resection, aneurysmectomy, and cryoablation. The operative mortality rate was 8%. Age greater than 65 years was the only risk factor for operative mortality. Forty-one patients underwent postoperative programmed electrical stimulation. In 26 patients (63%) tachycardia was noninducible, whereas it was inducible in 15 patients (37%). Stepwise logistic regression identified septal and inferior focus location as the most significant predictors of outcome. Septal focus location was a significant (p = 0.008) predictor of surgical success whereas inferior focus location was a significant (p = 0.015) predictor of surgical failure. Other identified independent risk factors for surgical failure were (1) use of cardioplegia, (2) lack of a completed intraoperative endocardial map, and (3) decreased ejection fraction. This generated model to predict success or failure had a sensitivity of 93.3% and a specificity of 92.4%. The success of ventricular operation is affected by the presence of certain risk factors. In the management of those patients at high risk for failure, other surgical options such as the placement of implantable cardioverter-defibrillator electrode patches at the time of ventricular operation or the alternative placement of a palliative implantable cardioverter-defibrillator should be considered.