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Klein HU, Trappe HJ, Frank G. [History of surgical treatment of cardiac arrhythmias in Germany : Surgical treatment of ventricular tachycardia and supraventricular tachycardia, especially pre-excitation syndromes (WPW)]. Herzschrittmacherther Elektrophysiol 2024; 35:88-97. [PMID: 38416160 PMCID: PMC10923999 DOI: 10.1007/s00399-024-01012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
The history of surgical treatment of ventricular tachycardias (VT) is short, lasting from 1978 until 1993. "Indirect procedures" with infarct scar resection were performed without electrophysiologic studies, whereas "direct procedures" consisted of either complete endocardial incisions ("encircling endocardial ventriculotomy") or large endocardial resections ("endocardial peel-off" technique) after precise epicardial and endocardial mapping procedures. In Germany, the first to report on intra-operative electrophysiologic mapping for VT treatment were Ostermeyer, Breithardt and Seipel in 1979. In 1981, the Hannover group (Frank, Klein) published their first results of surgical treatment of VT. In 1984, Ostermeyer et al. demonstrated that a partial endocardial incision resulted in more beneficial results with less myocardial damage (8% versus 46%) than applying a complete encircling incision. In 1987, the Düsseldorf group reported treatment results of 93 patients. After 5 years, 77% had no VT recurrence, while total mortality after 1 year was 11% and after 5 years 30%. In 1992, the Hannover group reported results of 147 patients after endocardial resection for VT. Total mortality after 3 years was 27%; recurrence of VT events occurred in 18% of the surviving cohort.The history of surgical procedures for supraventricular tachycardia (SVT), in particular Wolff-Parkinson-White (WPW) syndrome, is even shorter than that of surgery for VT. As early as 1969, Sealy, Gallagher and Cox reported the first cases of surgical intervention for WPW syndrome via endocardial access in cardioplegic arrest. In 1984, Guiraudon and Klein reported on a new procedure with epicardial access to the accessory bundle without cardioplegia in laterally localised conduction pathways. In Germany, too, the groups in Düsseldorf (Ostermeyer, Seipel, Breithardt, Borggrefe) from 1980 and the Hannover group (Frank, Klein and Kallfelz) from 1981 performed surgical procedures for WPW syndrome. In 1987, Borggrefe reported on 18 patients with WPW syndrome and atrial fibrillation who had undergone surgery. After 2 years, 14 of 18 patients had no recurrences of tachycardia; in 1989, Frank, Klein and Kallfelz (Hannover) reported on 10 children (2-14 years) operated on using the cryoablation technique. Between 1984 and 1992, a total of 120 patients with SVT, mostly WPW syndrome, were operated on in Hannover; after 42 months, 12 patients had a recurrence of SVT. Two patients died during the reoperation.
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Sugrue A, Maor E, Ivorra A, Vaidya V, Witt C, Kapa S, Asirvatham S. Irreversible electroporation for the treatment of cardiac arrhythmias. Expert Rev Cardiovasc Ther 2018; 16:349-360. [DOI: 10.1080/14779072.2018.1459185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel Asirvatham
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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FARRÉ JERÓNIMO, ANDERSON ROBERTH, CABRERA JOSÉA, SÁNCHEZ-QUINTANA DAMIÁN, RUBIO JOSÉM, BENEZET-MAZUECOS JUAN, DEL CASTILLO SILVIA, MACÍA ESTER. Cardiac Anatomy for the Interventional Arrhythmologist: I.Terminology and Fluoroscopic Projections. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:497-507. [DOI: 10.1111/j.1540-8159.2009.02644.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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FONTAINE G, GUIRAUDON G, FRANK R, TEREAU Y, PAVIE A, CABROL C, CHOMETTE G, GROSGOGEAT Y. Management of Ventricular Tachycardia Not Related To Myocardial Ischemia. ACTA ACUST UNITED AC 2008. [DOI: 10.1111/j.1540-8167.1984.tb01661.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- S C Krishnan
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston 02215, USA
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Reek S, Klein HU, Ideker RE. Can catheter ablation in cardiac arrest survivors prevent ventricular fibrillation recurrence? Pacing Clin Electrophysiol 1997; 20:1840-59. [PMID: 9249840 DOI: 10.1111/j.1540-8159.1997.tb03575.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Ventricular tachyarrhythmias are the most common cause for sudden cardiac death. The success of catheter ablation for supraventricular tachycardias led to the supposition that ablation could also be used in the treatment of ventricular tachycardias. Despite the promising results in bundle branch reentry and some forms of idiopathic ventricular tachycardia, the success rate in patients with coronary artery disease is still low. There is hope that new approaches to reliably localize the critical region of the tachycardia and new ablation techniques to create larger areas of injury may lead to a wider application of ablation therapy in the treatment of ventricular tachycardia. Survivors of cardiac arrest typically have more rapid and unstable arrhythmias than patients with sustained ventricular tachycardia, and these rapid arrhythmias frequently degenerate into ventricular fibrillation. The instability of the arrhythmia makes it impossible to localize the arrhythmia origin with current mapping techniques. Experimental and clinical data, however, suggest that these arrhythmias also frequently start from a localized area of electrical activation. With developments in mapping techniques and energy delivery, catheter ablation may soon become a feasible therapeutic approach in some patients with unstable arrhythmias. The article discusses the prerequisites for this approach and suggests the patients who may be appropriate candidates for this technique.
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Affiliation(s)
- S Reek
- Department of Medicine, University of Alabama at Birmingham 35294-0019, USA
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Rajasinghe HA, Lorenz HP, Longaker MT, Scheinman MM, Merrick SH. Arrhythmogenic ventricular aneurysms unrelated to coronary artery disease. Ann Thorac Surg 1995; 59:1079-84. [PMID: 7733701 DOI: 10.1016/0003-4975(95)00121-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Malignant ventricular tachycardia occurs most frequently in patients with coronary artery disease who have had a previous myocardial infarction and in whom a ventricular aneurysm subsequently develops in the scarred section of myocardium. Ventricular tachycardia in the presence of normal coronary arteries and a left ventricular aneurysm is unusual and can be refractory to medical therapy. We retrospectively reviewed our experience of 10 patients treated at our institution from 1983 to 1993. Age ranged from 22 to 76 years, and all patients presented with sustained ventricular tachycardia. All patients underwent complete electrophysiologic testing. Cardiac catheterization was performed in 9 patients, and each had normal coronary artery anatomy without evidence of significant fixed lesions. A left ventricular aneurysm, diagnosed by either echocardiography, thoracic cine computed tomography or magnetic resonance imaging, or ventricular angiography was present in all patients. Ventricular tachycardia could not be suppressed pharmacologically in 7 of 10 patients using multiple agents including procainamide, quinidine, flecanide, tocainide, propaferone, and amiodarone. Six patients were treated surgically by intraoperative electrophysiologic mapping, endocardial resection of foci, and left ventricular aneurysmectomy. An implantable cardiac defibrillation device was implanted in 2 patients. One patient died on the second postoperative day after simultaneous mapping -guided aneurysmectomy and implantable cardioverter defibrillator placement. There was one late postoperative death. All other surgically treated patients had postoperative electrophysiologic studies demonstrating no inducible ventricular tachycardia, and these patients remain without antiarrhythmic therapy in follow-up extending from 29 to 86 months (mean, 56 months).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H A Rajasinghe
- Division of Cardiothoracic Surgery, University of California, San Francisco 94143, USA
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Schoels W, Brachmann J, Hug R, Schmitt C, Kuebler W. Therapy assessment for sustained ventricular tachyarrhythmias: how many electropharmacological tests are appropriate? Pacing Clin Electrophysiol 1990; 13:663-72. [PMID: 1693206 DOI: 10.1111/j.1540-8159.1990.tb02084.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Surgery, implantable devices or catheter ablations offer therapeutic choices for the treatment of malignant ventricular tachyarrhythmias (VT) resistant to antiarrhythmic drugs. The number of electropharmacological (EP) tests that should precede consideration of a nonpharmacological therapy has not been defined. We performed serial EP tests in 94 patients with inducible sustained VT until an effective drug was identified or all available drugs had failed to suppress VT induction. With up to 11 tests in individual patients, suppression of VT inducibility was finally achieved in 66 patients (70%). In 47 of these 66 patients (70%), only one or two tests were necessary to identify an effective regimen. However, in 40%, 28%, 18%, and 9% of the patients still inducible after 2, 3, 4, and 5 drug tests, respectively, an effective agent could be identified during subsequent tests. No critical number of unsuccessful EP tests clearly separated responders and nonresponders to medical therapy. During follow-up (34 +/- 11 months), 14 patients placed on antiarrhythmic drugs predicted to be effective had symptomatic VT recurrence. VT recurrence was unrelated to the type or the number of unsuccessful EP tests preceding identification of the prescribed drug. Extensive EP testing with all available agents might therefore be worthwhile in selected patients. An "appropriate" number of EP studies has to be determined individually for each patient, based on the chance of finding an effective drug during subsequent studies and the risk and benefit of the therapeutic choices.
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Affiliation(s)
- W Schoels
- Department of Cardiology, University of Heidelberg, Federal Republic of Germany
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Iida S, Misaki T, Iwa T. The histological effects of cryocoagulation on the myocardium and coronary arteries. THE JAPANESE JOURNAL OF SURGERY 1989; 19:319-25. [PMID: 2674502 DOI: 10.1007/bf02471408] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The effects of epicardial and endocardial cryolesions were histologically studied in 29 dogs. To produce epicardial lesions, hypothermic exposure was applied at -60 degrees C for 3 minutes, over or adjacent to the left anterior descending coronary artery. To produce endocardial lesions, exposure was applied at -60 degrees C for 2 minutes, using the inflow occlusion technique over the ventricular septum. The dogs were killed 30 minutes to 6 months later. The cryolesions were sharply demarcated from the surrounding tissues and showed similar healing processes. The lesions showed no tendency to form aneurysms or rupture, although moderate intimal thickening of the coronary artery subjacent to the probe was observed. Our results indicate that cryocoagulation may greatly contribute to the surgical treatment of cardiac arrhythmias.
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Affiliation(s)
- S Iida
- Department of Surgery, Kanazawa University School of Medicine, Japan
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Mickleborough LL, Wilson GJ, Weisel RD, Mackay CA, Ivanov J, Takagi M, Akagawa H, McLaughlin PR, Baird RJ. Endocardial excision versus encircling endocardial ventriculotomy. J Thorac Cardiovasc Surg 1986. [DOI: 10.1016/s0022-5223(19)36001-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ward DE, Camm AJ. Treatment of tachycardias associated with the Wolff-Parkinson-White syndrome by transvenous electrical ablation of accessory pathways. Heart 1985; 53:64-8. [PMID: 3871331 PMCID: PMC481723 DOI: 10.1136/hrt.53.1.64] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Three patients with tachycardias associated with the Wolff-Parkinson-White syndrome had failed to respond to antiarrhythmic drugs and underwent transvenous ablation of accessory pathways. Intracardiac studies located the site of accessory pathway to the septum in two patients and mid-posterobasal left atrioventricular junction in one. Ablation was performed by positioning an electrode lead as close as possible to the accessory tract and delivering shocks of 50 to 100J using a conventional defibrillator. In all patients the accessory pathway was abolished after the first three shocks. In two patients followed for four and nine months there was no recurrence of tachycardia or pre-excitation. The other patient developed pre-excitation again three weeks later and repeat ablation was performed. This patient has been followed for six months with no evidence of a recurrence of pre-excitation. This method may provide a valuable alternative to pacemaker and surgical treatment in selected patients with drug resistant arrhythmias associated with accessory atrioventricular connexions.
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Scheinman MM, Morady F, Shen EN. Invasive electrophysiologic testing: a critical appraisal. Ann N Y Acad Sci 1984; 432:155-61. [PMID: 6395758 DOI: 10.1111/j.1749-6632.1984.tb14517.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Bardy GH, Packer DL, German LD, Gallagher JJ. Utility of electrophysiologic studies in the management of tachycardia, sudden death, and syncope. Ann N Y Acad Sci 1984; 427:16-39. [PMID: 6378012 DOI: 10.1111/j.1749-6632.1984.tb20772.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The demonstrable value of EP studies for any given diagnostic or therapeutic category, in the last analysis, is largely a function of the subjects studied. Extrapolations from published data (that generally reflect a highly select patient population) to an individual patient can be fraught with error. Considerations of sensitivity and specificity must be balanced against the important need for information in patients at risk from life-threatening arrhythmias. We must never forget, however, that the EP substrate for any arrhythmia is not, as one might wish, a "black box" that should be expected to respond in a reproducible fashion to stimulation. The substrate is dynamic and subject to modification by change in autonomic tone, stretch, blood flow, basal rate, pH, electrolytes, oxygenation, and exposure to perhaps as yet undiscovered humoral mediators. The challenge to the clinical electrophysiologist is therefore not to exaggerate his efforts in one direction (i.e. programmed stimulation) while disregarding the other variables mentioned. Nor should we be disappointed and discard this approach because our expectations of an oversimplified model of arrhythmia testing are not fulfilled. Thus, in addition to careful stratification of patients, baseline studies should perhaps be carried out with more deliberate consideration of autonomic tone (exercise, isoproterenol), stretch (volume, handgrip, afterload), stress (physical and psychological), local anesthetic used, and body position. Only in this way will the scientific basis for acute and chronic EP testing be firmly established.
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Heddle WF, Tonkin AM. Arrhythmias and antiarrhythmic agents*. Med J Aust 1984. [DOI: 10.5694/j.1326-5377.1984.tb113230.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Andrew M. Tonkin
- Department of Medicine Flinders Medical Centre Bedford Park SA 5042
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Downar E, Parson ID, Mickleborough LL, Cameron DA, Yao LC, Waxman MB. On-line epicardial mapping of intraoperative ventricular arrhythmias: initial clinical experience. J Am Coll Cardiol 1984; 4:703-14. [PMID: 6481011 DOI: 10.1016/s0735-1097(84)80396-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
An on-line automatic mapping system was developed for beat by beat display of epicardial activation during ventricular tachycardia induced at the time of cardiac surgery. A sock array of 110 button electrodes was used to record and display local activation on a video monitor at 8.3 ms intervals. On instant replay in slow motion, epicardial pacing sites were accurately localized to the nearest electrode. Local unipolar electrograms were also recorded, first from the sock array, then from an array of 16 transmural needle electrodes. The epicardial display was verified by retrospective manually derived maps using the recorded epicardial electrograms. In four patients with coronary artery disease and recurrent inducible ventricular tachycardia, earliest epicardial activation was located on slow motion replay within 1 minute. Subendocardial sites of early activation were located within 10 minutes by replay of electrograms from the needle array before ventriculotomy. Transmural and endocardial resection of these sites prevented inducibility of the tachycardia on postoperative electrophysiologic study in three of the four patients. There has been no clinical recurrence of ventricular tachycardia after 3 to 14 months of follow-up despite cessation of antiarrhythmic therapy in three of the patients. This technique has unique advantages over existing mapping methods. It provides beat by beat display of activation sequences so that clinical tachycardias that are short in duration or pleomorphic in configuration now become amenable to mapping. In addition, it markedly shortens total time on cardiopulmonary bypass.
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Ector H, Van Brabandt H, De Geest H. Treatment of life-threatening ventricular arrhythmias by a combination of antiarrhythmic drugs and right ventricular pacing. Pacing Clin Electrophysiol 1984; 7:622-7. [PMID: 6205361 DOI: 10.1111/j.1540-8159.1984.tb05588.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thirteen patients with intractable ventricular arrhythmias were studied; they underwent long-term treatment by a combination of antiarrhythmic drugs and ventricular pacing. Eleven patients had a history of tachycardia and two had torsade de pointes; eleven of thirteen had had cardioversion and/or defibrillation. Prior to permanent pacemaker implantation, temporary pacing in the VVI mode was used in combination with one or more of the following drugs: amiodarone, aprindine, digitalis, metoprolol, mexiletine, procainamide, pindolol, propranolol, or quinidine. Various pacing rates were tried; when permanent pacing was instituted, a unipolar system which was at least rate-programmable was used. Right ventricular VVI pacing, combined with drug therapy, was successful in ten of thirteen patients. Five of the ten patients are alive and free of arrhythmias after 78, 72, 72, 54, and 11 months, respectively. Although five patients died (after 60, 48, 30, 24, and 9 months, respectively), none of the deaths were related to arrhythmias. We suggest that in patients with ventricular arrhythmias refractory to conventional treatment, a therapeutic trial of right ventricular VVI pacing in combination with a drug regimen be used.
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Brodman R, Fisher JD, Johnston DR, Kim SG, Matos JA, Waspe LE, Scavin GM, Furman S. Results of electrophysiologically guided operations for drug-resistant recurrent ventricular tachycardia and ventricular fibrillation due to coronary artery disease. J Thorac Cardiovasc Surg 1984. [DOI: 10.1016/s0022-5223(19)37394-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Smith WM, Ideker RE, Smith WM, Kasell J, Harrison L, Bardy GH, Gallagher JJ, Wallace AG. Localization of septal pacing sites in the dog heart by epicardial mapping. J Am Coll Cardiol 1983; 1:1423-34. [PMID: 6853898 DOI: 10.1016/s0735-1097(83)80045-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
To examine whether different septal pacing sites could be distinguished by their epicardial activation patterns, six to eight stimulating electrodes were placed throughout the septum in seven open chest dogs. Unipolar electrograms were obtained from 52 epicardial electrodes during pacing from each stimulating electrode and isochronous epicardial maps were constructed. The location of each stimulating electrode was found by dissection, and its distance from the overlying epicardium was measured. To allow comparison among epicardial maps, the septum was conceptually subdivided into nine regions to which stimulating electrodes were assigned. Epicardial activation patterns from the same region were similar and these patterns allowed the region containing a stimulating electrode to be identified in many cases. Three other variables were found to have additional localizing value. There were: 1) the time from the stimulus to epicardial breakthrough, 2) the duration of epicardial activation, and 3) the area of epicardium activated in the first 5 ms after epicardial breakthrough. For those stimulating electrodes that could not be localized by their epicardial activation patterns, the distance of the stimulating electrode beneath the epicardium was well fit from these three variables by multiple regression (correlation coefficient [r] = 0.97). Thus, using all the previous factors, localization of septal pacing sites was possible in the noninfarcted dog heart by epicardial mapping.
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Abstract
All cardiac arrhythmias are either automatic or reentrant. Automatic arrhythmias occur in the periinfarction or perioperative period. Chronic, recurrent arrhythmias are typically reentrant. By definition, reentrant arrhythmias are inducible with programmed electrical stimulation. When a malignant cardiac arrhythmia is identified, the patient is taken to the electrophysiologic laboratory for study. Reentrant ventricular tachyarrhythmias are induced with programmed electrical stimulation. Pharmacologic suppression is guided by electrophysiologic testing. When antiarrhythmic suppression fails, surgical intervention may be an effective alternative. Endocardial catheter mapping before surgery may serve as an important guide to the surgeon. Myocardial mapping is clinically valuable only when all antiarrhythmic therapy has failed, and the patient is considered to be a candidate for surgical intervention. When surgical intervention is planned, we consider preoperative catheter mapping desirable and intraoperative electrophysiologic localization mandatory.
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Marquez-Montes J, Rufilanchas JJ, Esteve JJ, Alvarez L, Benezet J, Burgos R, Figuera D. Paroxysmal nodal reentrant tachycardia. Surgical cure with preservation of atrioventricular conduction. Chest 1983; 83:690-4. [PMID: 6831959 DOI: 10.1378/chest.83.4.690] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
In a patient with repetitive disabling tachycardias refractory to pharmacologic treatment, the electrophysiologic study suggested the existence of atrioventricular nodal reciprocating tachycardia. During ventricular pacing, endoepicardial mapping of the lower atrium showed the atrial breakthrough point in an area of the lower interatrial septum close to the AV node crista. A selective atriotomy was performed. The postoperative electrophysiologic studies showed absence of ventriculoatrial conduction at several ventricular pacing rates, while antegrade conduction is preserved. The patient remained free of arrhythmias 21 months after surgery, taking no antiarrhythmic drugs.
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Abstract
Ventricular ectopy occurs commonly. Its significance is related to the degree of complexity and the associated cardiac substrate. Coronary artery disease is the most frequent underlying cause, followed by cardiomyopathy and valvular disease. Symptomatic ventricular arrhythmias require treatment, whereas benign simple ventricular ectopy does not; however, the treatment of asymptomatic high-grade ventricular ectopy remains controversial. Therapy first must be directed toward the cardiac disease. Evaluation of the patient includes Holter monitoring, echocardiography, radionuclide studies, exercise testing, cardiac catheterization, and electrophysiologic testing. Programmed stimulation is useful in the diagnosis and prognosis of ventricular tachycardia, as well as in the evaluation of drug regimen efficacy. After treatment of ischemia and/or failure, specific antiarrhythmic agents, conventional and investigational, alone or in combination, are systematically selected. Should medical therapy alone be insufficient, consideration is given to surgical procedures such as subendocardial resection or ventriculotomy, often in combination with bypass grafting, aneurysmectomy, or valvular replacement. Electronic devices, including pacemakers or automatic internal defibrillators, may also be useful in certain selected cases. Suggested guidelines are proposed for a standardized approach, although therapy for each patient must still be individualized.
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Ostermeyer J, Breithardt G, Kolvenbach R, Borggrefe M, Seipel L, Schulte HD, Bircks W, Kirklin JW. The surgical treatment of ventricular tachycardias. J Thorac Cardiovasc Surg 1982. [DOI: 10.1016/s0022-5223(19)38960-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Dunnigan A, Benditt DG, Fetter J, Anderson RW, Fuhrman BP, Benson DW. A patient-activated radio frequency pacemaker system: therapy for recurrent ventricular tachycardia. J Pediatr 1982; 101:403-6. [PMID: 7108661 DOI: 10.1016/s0022-3476(82)80069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Strasberg B, Fetter J, Palileo E, Levitsky S, Rosen KM. Postoperative electrophysiological studies with a modified radiofrequency system. Technical aspects and clinical usefulness. Pacing Clin Electrophysiol 1982; 5:688-93. [PMID: 6182540 DOI: 10.1111/j.1540-8159.1982.tb02306.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Two patients who underwent a ventricular aneurysmectomy for treatment of ventricular tachycardia are presented. In both patients, a radiofrequency pacemaker was implanted at surgery (for therapeutic use if surgery should fail). In both patients, electrophysiological studies were performed before discharge utilizing a radiofrequency pacemaker without recourse to repeat catheterization. This was possible by modifying the transmitter and coupling it to a commercially available programmable stimulator.
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Ohkawa S, Hackel DB, Mikat EM, Gallagher JJ, Cox JL, Sealy WC. Anatomic effects of cryoablation of the atrioventricular conduction system. Circulation 1982; 65:1155-62. [PMID: 7074775 DOI: 10.1161/01.cir.65.6.1155] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Because of the value of cryoablation of the atrioventricular (AV) conduction system in treatment of refractory cardiac rhythm disorders, the anatomic effects of cryoablation on the cardiac conduction system must be defined. In this report we summarize studies done on four patients who had intractable recurrent supraventricular tachyarrhythmias or or refractory atrial flutter-fibrillation. They were treated by cryoablation of the AV conduction system and died 8-360 days postoperatively. Serial sections of the AV conduction system were studied. Cryoablation produced lesions that completely destroyed most of the AV node in three cases, the penetrating portion of the His bundle in all four cases, and the branching portion of the His bundle in two cases. The right bundle branch was not involved markedly in any case. The lesions were discrete and sharply delimited; the patient who died 8 days postoperatively had hemorrhage, necrosis and slight inflammatory infiltrate; patients who survived for 49-360 days showed collagen deposition. The AV nodal artery and its branches showed slight to marked intimal thickening in three cases. Small, partly organized thrombi were present just behind the tricuspid valve in two patients. We conclude that cryoablation of the AV conduction system produced discrete cardiac lesions that did not markedly damage the tricuspid valve or aorta.
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Spotnitz HM, Gliklich JI, Ross S, Reiffel JA, Malm JR, Bigger JT, Hoffman BF. Four-contact glove probe method for rapid recording of cardiac electrograms during surgery. Ann Thorac Surg 1982; 33:403-5. [PMID: 7073385 DOI: 10.1016/s0003-4975(10)63238-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
A technique is presented for recording four simultaneous electrograms from the heart during operation for cardiac arrhythmias. this technique permits intraoperative maps of cardiac electrical activity to be constructed more rapidly than is possible with single-point mapping, thereby decreasing the risks to the patient and yielding more information about cardiac events.
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Fontaine G, Guiraudon G, Frank R, Fillette F, Cabrol C, Grosgogeat Y. Surgical management of ventricular tachycardia unrelated to myocardial ischemia or infarction. Am J Cardiol 1982; 49:397-410. [PMID: 7036705 DOI: 10.1016/0002-9149(82)90517-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Gallagher JJ, Kasell JH, Cox JL, Smith WM, Ideker RE, Smith WM. Techniques of intraoperative electrophysiologic mapping. Am J Cardiol 1982; 49:221-40. [PMID: 7032270 DOI: 10.1016/0002-9149(82)90296-x] [Citation(s) in RCA: 147] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Cardiac mapping during sinus rhythm and during spontaneous or induced ventricular arrhythmias is a promising technique that offers a variety of potential strategies to improve our ability to locate abnormal areas in the heart that are the seat of arrhythmias. If surgical procedures are to become more limited in scope in an attempt to salvage myocardium, mapping will need to be used to a greater extent. However, it remains to be established which mapping technique will prove most sensitive and specific in detecting sites of arrhythmia, and whether the localizing method used allows a more directed surgical intervention to be successful.
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Hamer AW, Vohra JK, Sloman JG, Hunt D. The management of patients with suspected Wolff-Parkinson-White Syndrome--a four year review. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1981; 11:629-38. [PMID: 7036971 DOI: 10.1111/j.1445-5994.1981.tb03537.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Tonkin A. Recognition and management of supraventricular tachyarrhythmias. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1981; 11:697-705. [PMID: 6949547 DOI: 10.1111/j.1445-5994.1981.tb03549.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
While the principles of drug management of supraventricular tachyarrhythmias have remained essentially unchanged, such treatment remains empirical in many patients. Recent advances in the understanding of electrophysiological mechanisms have not only rationalised treatment but dictated newer approaches to these and other arrhythmias.
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Guiraudon G, Fontaine G, Frank R, Leandri R, Barra J, Cabrol C. Surgical treatment of ventricular tachycardia guided by ventricular mapping in 23 patients without coronary artery disease. Ann Thorac Surg 1981; 32:439-50. [PMID: 7305530 DOI: 10.1016/s0003-4975(10)61775-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Twenty-three patients with resistant ventricular tachycardia not related to coronary artery disease underwent surgical treatment guided by ventricular mapping. The patients were grouped according to radiological and anatomical findings. Group 1 (13 patients) had arrhythmogenic right ventricular dysplasia. Group 2 (3 patients) had left ventricular aneurysm. Group 3 (2 patients) had nonobstructive myocardiopathy. Group 4 (5 patients) had normal-appearing hearts. At operation all patients underwent ventricular mapping when in sinus rhythm and during ventricular tachycardia. The rationale of operation was ventriculotomy or cryosurgery at the site of origin of ventricular tachycardia or exclusion, resection, or undermining of arrhythmogenic areas where delayed potentials were observed. Four patients died during the perioperative period, 3 of low-output failure and 1 from bleeding. Ventricular tachycardia recurred immediately after operation in 4 patients, 3 of whom died during the perioperative period. Ventricular tachycardia recurred late in 5 patients. Three had only episodic, unsustained runs of tachycardia. Two were well controlled by drugs. All patients with ventricular tachycardia situated over the free wall of the ventricles had inducible ventricular tachycardia and had good surgical results. Three out of 5 patients with ventricular tachycardia situated in the septum had poor surgical results. Septal ventricular tachycardia needs a better surgical approach to the septum and a suitable surgical concept.
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Hecht HS, Taylor R, Wong M, Shah PM. Comparative evaluation of segmental asynergy in remote myocardial infarction by radionuclide angiography, two-dimensional echocardiography, and contrast ventriculography. Am Heart J 1981; 101:740-9. [PMID: 7234651 DOI: 10.1016/0002-8703(81)90609-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Radionuclide angiography (RNA), two-dimensional echocardiography (2DE), and contrast ventriculography (CVG) were compared in the evaluation of regional wall motion (RWM) in 58 patients with remote myocardial infarction (MI). All 58 patients were studied by 2DE, 52 by RNA, and 24 by CVG. Severe degrees of segmental asynergy (akinesia/dyskinesia) were noted more often by 2DE (56% of all segments, p less than 0.005) and CVG (52%, p less than 0.05) than by RNA (39%). The apex more the most frequent site of akinesia/dyskinesia by all technique (43% by RNA, 36% by 2DE, and 45% by CVG). 2DE and RNA agreed in 64% of regions (p less than 0.005), 2DE and CVG agreed in 68% (p less than 0.005), and RNA and CVG agreed in 70% (p less than 0.005); the highest agreement was for the apical region. Dyskinesia was noted in 77% of patients by RNA, in 71% by 2DE, and 79% by CVG. RNA and CVG agreed in 89% of patients and in 57% of regions, 2DE and CVG agreed in 67% of patients and in 53% of regions, and RNA and 2DE agreed in 71% of patients and in 38% of regions. Combined RNA and 2DE detected dyskinesia in 94% of the 16 patients with dyskinesia by CVG who underwent all three techniques and in 90% of the 52 patients studied by RNA and 2DE. We conclude that (1) RNA, 2DE an CVG agree significantly in the evaluation of regional wall motion; (2) there is better agreement concerning the presence or absence of dyskinesia in a given patients than the exact region involved; and (3) the combination of RNA and 2DE is more useful than either alone as a screening procedure for the detection of ventricular dyskinesia.
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Waldo AL, Arciniegas JG, Klein H. Surgical treatment of life-threatening ventricular arrhythmias: the role of intraoperative mapping and consideration of the presently available surgical techniques. Prog Cardiovasc Dis 1981; 23:247-64. [PMID: 7008078 DOI: 10.1016/0033-0620(81)90015-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Recurrent ventricular tachycardia is a well-recognized complication of ischemic heart disease. Coronary bypass operation with or without aneurysmectomy has been disappointing as therapy for these arrhythmias. With the advent of programmed electrical stimulation, it has become possible to distinguish automatic and reentrant ventricular tachyarrhythmias. The latter have recently proved amenable to operative intervention. This review examines the pathophysiology and diagnosis of ventricular tachycardia using programmed electrical stimulation. Surgical therapy with resection, revascularization, autonomic modulation, thermal ablation, cardiac pacing, reentrant circuit interruption, and endocardial excision is explored. Operation for cardiac arrhythmias is on a firm electrophysiological foundation. Surgical treatment of refractory ventricular tachyarrhythmias is now rational, recommended, and rewarding.
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Harrison L, Ideker RE, Smith WM, Klein GJ, Kasell J, Wallace AG, Gallagher JJ. The sock electrode array: a tool for determining global epicardial activation during unstable arrhythmias. Pacing Clin Electrophysiol 1980; 3:531-40. [PMID: 6160551 DOI: 10.1111/j.1540-8159.1980.tb05272.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The conventional technique for mapping the sequence of epicardial activation uses a hand-held electrode moved over the heart to record from a number of epicardial sites one at a time, and requires 5-15 minutes to record from 50 or more sites distributed over the entire ventricular epicardium. This method is inadequate for arrhythmias that are transient or vary from beat to beat. To overcome these limitations the "sock electrode array," a contour-fitting sock containing 26 or 52 electrodes, has been developed. The nylon mesh sock is pulled over the heart and permits simultaneous recording of potentials from electrodes distributed over the entire ventricular epicardium. The electrograms are recorded and converted to digital form for computer generation of isochronous maps. Most of the epicardial activation sequence derived from the sock electrode were compared to those obtained by the hand-held electrode in six normal dogs during sinus rhythm and ventricular pacing. The sequence of local activation times acquired by both methods showed similar areas of early and late activation and comparable isochronous maps. The hand-held electrode technique required 10-15 minutes for data acquisition and another 15-30 minutes for analysis. The sock electrode array allowed electrograms from 26 epicardial electrodes to be recorded simultaneously during one cardiac cycle and computer generated isochronous maps could be displayed within 10 minutes. This method allows rapid recording and analysis of epicardial electrical phenomena and should meet the time constraints imposed during the intraoperative study of ventricular tachyarrhythmias in patients.
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Horowitz LN, Josephson ME, Kastor JA. Intracardiac electrophysiologic studies as a method for the optimization of drug therapy in chronic ventricular arrhythmia. Prog Cardiovasc Dis 1980; 23:81-98. [PMID: 6997925 DOI: 10.1016/0033-0620(80)90006-7] [Citation(s) in RCA: 159] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Camm J, Ward DE, Spurrell RA, Rees GM. Cryothermal mapping and cryoablation in the treatment of refractory cardiac arrhythmias. Circulation 1980; 62:67-74. [PMID: 7379286 DOI: 10.1161/01.cir.62.1.67] [Citation(s) in RCA: 86] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Horowitz LN, Harken AH, Kastor JA, Josephson ME. Ventricular resection guided by epicardial and endocardial mapping for treatment of recurrent ventricular tachycardia. N Engl J Med 1980; 302:589-93. [PMID: 7351905 DOI: 10.1056/nejm198003133021101] [Citation(s) in RCA: 238] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recurrent, medically refractory ventricular tachycardia is usually associated with ventricular aneurysms after myocardial infarction, but aneurysmectomy alone has not been consistently effective in abolishing this dangerous arrhythmia. Therefore, we have used endocardial and epicardial mapping during induced ventricular tachycardia in 30 consecutive patients to identify the probable site where arrhythmia originated in the endocardial tissue. Complete resection of the site was possible in 27 patients, and partial resection in three. In addition aneurysmectomy was performed in 27 patients, and coronary-bypass grafting in 21. There were two operative and three late nonarrhythmic deaths. None of the 25 surviving patients have had ventricular tachycardia during follow-up of four to 28 months; three patients, who had incomplete resections, have required antiarrhythmic drugs. We conclude that surgical therapy of recurrent ventricular tachycardia can be improved through identification of the endocardial origin of the arrhythmia followed by appropriately guided resection.
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Pritchett EL, Prystowsky EN, Benditt DG, Gallagher JJ. 'Dual atrioventricular nodal pathways" in patients with Wolff-Parkinson-White syndrome. Heart 1980; 43:7-13. [PMID: 7356864 PMCID: PMC482235 DOI: 10.1136/hrt.43.1.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
'Dual atrioventricular nodal pathways" were found in five patients who also had the Wolff-Parkinson-White syndrome. All five patients had a re-entrant tachycardia that used the atrioventricular node for conduction in the anterograde direction and an accessory atrioventricular pathway for conduction in the retrograde direction. One of the patients also had a re-entrant tachycardia that originated within the atrium or the atrioventricular node. Dual atrioventricular nodal pathways were identified in three of the five patients during their first electrophysiological study because the effective refractory period of the accessory atrioventricular pathway in the anterograde direction was longer than the effective refractory period of the fast atrioventricular nodal pathway. In the other two patients the dual atrioventricular nodal pathways were found only after operative division of an accessory atrioventricular pathway. Re-entrant tachycardia that uses an accessory pathway may be cured by operative division of the accessory pathway. Tachycardia resulting from re-entry within the atrioventricular node cannot be cured by an operation unless the normal conduction system is divided and a permanent pacemaker implanted. These five patients indicate the importance of determining the aetiology of tachycardia by studying the tachycardia itself and not only the type of atrioventricular conduction present.
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Josephson ME, Harken AH, Horowitz LN. Endocardial excision: a new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation 1979; 60:1430-9. [PMID: 498470 DOI: 10.1161/01.cir.60.7.1430] [Citation(s) in RCA: 339] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Twelve patients with medically refractory ventricular tachycardia secondary to ischemic heart disease underwent surgery for cure of their arrhythmia. Preoperatively, the tachycardia could be reproducibly initiated and terminated in each patient by programmed stimulation. In all instances, intraoperative mapping localized the tachycardia to the border of the aneurysm, a site not routinely resected during aneurysmectomy. In nine instances, the area of origin involved the septum. During bypass the tachycardia could still be induced after standard aneurysmectomy or ventriculotomy in 11 of 12 patients. On the basis of intraoperative mapping, resection of endocardium in the area of origin (25--40% the circumference of the aneurysmectomy) up to normal muscle was performed. In one patient without a discrete aneurysm, endocardial excision alone through a ventriculotomy was performed. There was one operative death due to cardiogenic shock (preoperative ejection fraction 5%) and one late death due to rupture of a mycotic aneurysm in the pulmonary artery. Before discharge, all patients underwent a repeat relectrophysiologic study off antiarrhythmic agents and in none could ventricular tachycardia be initiated. Hemodynamic and angiographic catheterization showed improved hemodynamics and ejection fractions in all. The 10 survivors remained free of sustained ventricular tachycardia for 9--20 months, with one late nonarrhythmic death.
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Ward DE, Camm AJ, Pearce RC, Spurrell RA, Rees GM. Incessant atrioventricular tachycardia involving an accessory pathway: preoperative and intraoperative electrophysiologic studies and surgical correction. Am J Cardiol 1979; 44:428-34. [PMID: 474421 DOI: 10.1016/0002-9149(79)90392-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Leutenegger F, Giger G, Fuhr P, Raeder EA, Burkart F, Schmitt H, Grädel E, Burckhardt D. Evaluation of aortocoronary venous bypass grafting for prevention of cardiac arrhythmias. Am Heart J 1979; 98:15-9. [PMID: 313145 DOI: 10.1016/0002-8703(79)90315-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The influence of ACB on cardiac arrhythmias was examined in 27 patients. Eight-hour Holter monitoring was performed 8 days preoperatively and 100 days postoperatively. Arrhythmias were divided into 3 groups (Class I: NSR +/- occasional APBs; Class II: less than five unifocal VPBs per minute; Class II: more than five VPBs per minute, multifocal VPBs, VPBs in a row or VT). Preoperative classification disclosed that 13 patients (48.1 per cent) were in Class I, six patients (22.2 per cent) were in Class II, and eight patients (29.6 per cent) were in Class III. The corresponding values after surgery were 10 patients (37.0 per cent), 13 patients (48.1 per cent), and four patients (14.8 per cent). These differences were not statistically significant (p less than 0.1). In view of the tendency of arrhythmias of Class III to improve after ACB, we feel that further investigations in this area are needed. At the present time ventricular arrhythmias alone constitute no indication for bypass surgery.
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