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Abstract
The treatment of drug-refractory chronic ventricular tachycardia (VT) has undergone a revolution over the last 50 years. We now have automatic implantable cardioverter defibrillator therapy with pace-terminating capabilities, and catheter ablation of VT has refined mapping and improved methods of lesion generation. Between 1980 and 1993, Houston Methodist Hospital became a leader in the diagnosis and surgical ablation of VT and other arrhythmias. This is a brief account of that period and some of the experiences and lessons that have led to significant advances used today.
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Affiliation(s)
- Gerald M Lawrie
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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2
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Yamada T, Doppalapudi H, McElderry HT, Plumb VJ, Kay GN. Demonstration of a right ventricular substrate of ventricular tachycardia after myocardial infarction. Europace 2010; 13:133-5. [PMID: 20858693 DOI: 10.1093/europace/euq345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A 57-year-old man with prior anteroseptal myocardial infarction underwent catheter ablation of ventricular tachycardia (VT) exhibiting a left bundle branch block QRS morphology. After failed left ventricular ablation, catheter ablation from the right ventricle (RV) eliminated the VT. An RV voltage map demonstrated an area of low voltage around the successful ablation site that likely allowed for a VT substrate.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd AVE S, Birmingham, AL 35294-0019, USA.
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3
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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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4
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Lustgarten DL, Keane D, Ruskin J. Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis 1999; 41:481-98. [PMID: 10445872 DOI: 10.1016/s0033-0620(99)70024-1] [Citation(s) in RCA: 186] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cryosurgery has been an integral part of the surgical management of cardiac arrhythmias since the late 1970s. With the recent development of intravenous cryocatheters, the use of cryothermy in the treatment of cardiac arrhythmias will increase in the near future. The following discussion includes a detailed consideration of the mode of tissue injury associated with cryothermy and a comprehensive review of cryosurgery in the management of a variety of cardiac arrhythmias. Cryosurgical management of supraventricular and ventricular tachycardias has proven to be both safe and effective. Cryothermal tissue injury is distinguished from hyperthermic injury by the preservation of basic underlying tissue architecture and minimal thrombus formation. Such differences will be particularly important in settings requiring extensive lesion formation, such as catheter-based maze procedures for the treatment of atrial fibrillation.
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Affiliation(s)
- D L Lustgarten
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston 02114, USA
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5
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Menz V, Duthinh V, Callans DJ, Schwartzman D, Gottlieb CD, Marchlinski FE. Right ventricular radiofrequency ablation of ventricular tachycardia after myocardial infarction. Pacing Clin Electrophysiol 1997; 20:1727-31. [PMID: 9227777 DOI: 10.1111/j.1540-8159.1997.tb03549.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Radiofrequency transcatheter ablation of ventricular tachycardia in the setting of a prior myocardial infarction is typically performed with application of energy to the left ventricular endocardium. In this article, two cases are described in which successful radiofrequency transcatheter ablation of ventricular tachycardia occurred with energy delivery to the right ventricular septum after failed ablation attempts from the left ventricle. Both patients had tachycardias with a left bundle branch block morphology and markedly presystolic activity recorded from the right ventricular septum. Right ventricular septal activation mapping during ventricular tachycardia should be performed in patients with left bundle branch block tachycardia morphology and coronary artery disease to maximize efficacy of the catheter ablation procedure.
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Affiliation(s)
- V Menz
- Philadelphia Heart Institute, Presbyterian Medical Center, Pennsylvania, USA
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6
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Hargrove WC, Addonizio VP, Miller JM. Surgical therapy of ventricular tachyarrhythmias in patients with coronary artery disease. J Cardiovasc Electrophysiol 1996; 7:469-80. [PMID: 8722593 DOI: 10.1111/j.1540-8167.1996.tb00553.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- W C Hargrove
- Medical College of Pennsylvania Hospital, Philadelphia, USA
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7
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Levy RD, Bennett DH. Catheter ablation of the atrioventricular junction by radiofrequency energy delivered across the interventricular septum using a left sided approach. Int J Cardiol 1993; 41:153-6. [PMID: 8282439 DOI: 10.1016/0167-5273(93)90155-a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We describe seven successful cases of ablation of the atrioventricular (AV) junction by passing radiofrequency (RF) energy between the tip of an electrode on the left ventricular aspect of the interventricular septum and a further electrode on the right side of the His bundle. All had undergone unsuccessful attempts at conventional unipolar RF ablation from the right and left side of the heart.
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Affiliation(s)
- R D Levy
- Regional Cardiothoracic Centre, Wythenshawe Hospital, Manchester, UK
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Bakker PF, Vermeulen FE, de Boo JA, Elbers HR, der Tweel IV, Beyeren IV, Duyff P, Borst C, Robles de Medina EO, Tuntelder JR. Extensive cryoablation of the left ventricular posterior papillary muscle and subjacent ventricular wall. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)33819-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hunt GB, Chard RB, Ross DL. Effect of ventriculotomy on postinfarction ventricular tachycardia in a canine model. Int J Cardiol 1993; 38:73-80. [PMID: 8444505 DOI: 10.1016/0167-5273(93)90206-v] [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: 01/30/2023]
Abstract
The antiarrhythmic efficacy of ventriculotomy without further resection or ablation was evaluated in 15 dogs with reliably inducible ventricular tachycardia after experimental myocardial infarction. The dogs were placed on cardiopulmonary bypass and assigned to one of two treatment groups: (1) cardiopulmonary bypass only (control) - 5 dogs, (2) ventriculotomy through the infarct scar - 10 dogs. The effects on induction of ventricular tachycardia were evaluated 2 and 4 weeks postoperatively and infarct histology was examined at the termination of the experiment. All of the control dogs maintained inducible ventricular tachycardia postoperatively. In contrast, ventriculotomy abolished arrhythmia induction in 6 of 10 dogs (p < 0.05). Ventriculotomy resulted in destruction of the surviving subepicardial myocardium overlying the infarct, which is a feature of arrhythmogenic areas in this model of postinfarction ventricular tachycardia. In conclusion, inducibility of ventricular tachycardia in this canine model of myocardial infarction is unaffected by thoracotomy and cardiopulmonary bypass, and is therefore well suited to investigation of surgical antiarrhythmic interventions. Ventriculotomy results in subepicardial scarring and is significantly antiarrhythmic. This effect should be taken into account when evaluating any adjunctive procedure in this model.
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Affiliation(s)
- G B Hunt
- Cardiology Unit, Westmead Hospital NSW, Australia
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Kim SG, Fisher JD, Choue CW, Gross J, Roth J, Ferrick KJ, Brodman R, Furman S. Influence of left ventricular function on outcome of patients treated with implantable defibrillators. Circulation 1992; 85:1304-10. [PMID: 1555274 DOI: 10.1161/01.cir.85.4.1304] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The outcomes of patients treated with implantable defibrillators were compared between patients with left ventricular ejection fraction greater than or equal to 30% and less than 30%. METHODS AND RESULTS Of 68 consecutive patients treated with implantable defibrillators, 40 patients (group 1) had left ventricular ejection fraction greater than or equal to 30%, and 28 patients (group 2) had left ventricular ejection fraction less than 30%. Sudden death, surgical mortality, nonsudden arrhythmia-related death (death within 24 hours after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillator), total arrhythmia-related death (including sudden death, surgical death, and nonsudden arrhythmia-related death), and total cardiac death were compared between the two groups. Surgical mortality was 4.4% (0% in group 1, 11% in group 2). During the follow-up of 31 +/- 27 months, actuarial survival rates free of events were 97%, 97%, and 97% in group 1 and 96%, 91%, and 82% in group 2 at 12, 24, and 36 months, respectively, for sudden death (p = NS); 97%, 97%, and 97% in group 1 and 85%, 81%, and 72% in group 2 at 12, 24, and 36 months, respectively, for sudden death and surgical mortality (p less than 0.05); 97%, 97%, and 97% in group 1 and 82%, 78%, and 70% in group 2 at 12, 24, and 36 months, respectively, for total arrhythmia-related death (p less than 0.05); and 95%, 95%, and 95% in group 1 and 82%, 69%, and 57% in group 2 at 12, 24, and 36 months, respectively, for total cardiac death (p less than 0.05). Four (57%) of seven nonsudden cardiac deaths during the initial 36-month follow-up period were causally related to arrhythmia (three surgical deaths and one arrhythmia-related nonsudden death). CONCLUSIONS The outcome of patients treated with implantable defibrillators is strongly influenced by the degree of left ventricular dysfunction. In group 1 patients, surgical mortality, sudden death, and total cardiac death are rare. In group 2, sudden death rate may not be markedly different from that of group 1 patients. However, the risk of therapy (surgical mortality) is high. Many nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or nonsudden arrhythmia-related death). Therefore, the survival rate free of total arrhythmia-related death is significantly lower in group 2 (70% versus 97% in group 1 at 3 years). Further studies are needed to determine the roles of defibrillator therapy and other therapies in various clinical settings.
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Affiliation(s)
- S G Kim
- Department of Medicine, Montefiore Medical Center/Moses Division, Bronx, NY 10467
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11
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Kim SG, Fisher JD, Furman S, Gross J, Zilo P, Roth JA, Ferrick KJ, Brodman R. Exacerbation of ventricular arrhythmias during the postoperative period after implantation of an automatic defibrillator. J Am Coll Cardiol 1991; 18:1200-6. [PMID: 1918696 DOI: 10.1016/0735-1097(91)90536-i] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The postoperative course of 68 consecutive patients treated with an implantable defibrillator during the period from 1982 through 1990 was studied. In 46 patients (group 1), no concomitant surgery was performed during the implantation. In 22 patients (group 2), concomitant surgery (coronary artery bypass [n = 12], valve replacement [n = 3] or arrhythmia surgery [n = 7]) was performed. All patients in group 1 were clinically stable before surgery, receiving an antiarrhythmic regimen chosen by serial drug testings. The same regimen was continued postoperatively. Eight of the 46 patients in group 1 whose condition had been stable in the hospital for 19 +/- 25 days preoperatively developed multiple episodes of sustained ventricular tachycardia 4 +/- 9 days after implantation while receiving the same antiarrhythmic regimen. Although the exacerbation was transient in some patients, six required different antiarrhythmic therapy and one eventually died. Two additional patients had frequent and prolonged episodes of nonsustained ventricular tachycardia that could trigger the defibrillator, requiring changes in the antiarrhythmic regimen. Another patient had progressive cardiac failure and died on day 5. A marked (sevenfold) increase in asymptomatic ventricular arrhythmias was noted in 42% of the remaining 35 patients. In group 2 (combined surgery), one patient developed refractory ventricular tachycardia 3 days postoperatively and died on that day. Three patients developed frequent nonsustained ventricular tachycardia postoperatively, requiring changes in the antiarrhythmic regimen. The overall surgical mortality rate was 4.4% (4.3% in group 1 and 4.5% in group 2) and was due to refractory ventricular tachycardia in two patients and cardiac failure in one.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S G Kim
- Departmnentof Medicine, Montefiore Medical Center/Moses Division, Bronx, New York 10467
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12
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Kim SG, Fisher JD, Furman S, Gross J, Zilo P, Roth JA, Ferrick KJ, Brodman R. Benefits of implantable defibrillators are overestimated by sudden death rates and better represented by the total arrhythmic death rate. J Am Coll Cardiol 1991; 17:1587-92. [PMID: 2033191 DOI: 10.1016/0735-1097(91)90652-p] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Benefits of the implantable defibrillator on survival were studied in 56 consecutive patients (concomitant coronary bypass or arrythmia surgery in 15) during an 8 year period between 1982 and 1990. During a follow-up period of 29 +/- 25 months, six patients had a sudden death and eight patients had a nonsudden cardiac death. Nonsudden cardiac deaths included three surgical deaths (death within 30 days after the surgery; two in patients without and one in a patient with concomitant cardiac surgery), one arrhythmia-related nonsudden death (death within 24 h after an arrhythmic event despite initial termination of the arrhythmia by the implantable defibrillators) and four nonarrhythmic cardiac deaths. The actuarial survival rate free of events at 1, 2 and 3 years was 96%, 96% and 92%, respectively, for sudden death, 91%, 91% and 87% for sudden death and surgical mortality and 89%, 89% and 85% for total arrhythmic death (sudden death, surgical mortality and arrhythmia-related nonsudden death). Thus, in patients treated with an implantable defibrillator, 1) the rate of sudden death is low (8% at 3 years); 2) 50% of nonsudden cardiac deaths are causally related to arrhythmia (surgical mortality or arrhythmia-related nonsudden death); 3) the total arrhythmic death rate is substantially higher than the sudden death rate; and 4) benefits of an implantable defibrillator are overestimated by reported sudden death and nonsudden cardiac death rates. The benefits may be better represented by the total arrhythmic death and nonarrhythmic cardiac death rates.
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Affiliation(s)
- S G Kim
- Department of Medicine, Montefiore Medical Center, Bronx, New York 10467
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13
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Factors predictive of results of direct ablative operations for drug-refractory ventricular tachycardia. J Thorac Cardiovasc Surg 1991. [DOI: 10.1016/s0022-5223(19)36792-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Landymore RW, Gardner MA, McIntyre AJ, Barker RA. Surgical intervention for drug-resistant ventricular tachycardia. J Am Coll Cardiol 1990; 16:37-41. [PMID: 2358599 DOI: 10.1016/0735-1097(90)90452-u] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endocardial resection was required in 26 patients with sustained drug-resistant ventricular tachycardia. The early mortality rate (within 30 days after operation) was 12%. Two deaths were the result of low cardiac output, and the third death was related to recurrent ventricular septal defect after septal endocardial resection. The survivors of endocardial resection were followed up from 6 to 92 months (mean 43). There were no recurrences of ventricular arrhythmias, and patients did not require antiarrhythmic drug therapy. The late mortality rate after endocardial resection was 19%. There were two late cardiac-related deaths (unrelated to arrhythmias) and three late deaths from noncardiac causes. Complete endocardial resection successfully ablates drug-resistant ventricular tachycardia, but is associated with an increased perioperative mortality rate in those patients who have severely depressed left ventricular function without a well defined left ventricular aneurysm.
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Affiliation(s)
- R W Landymore
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Laser Modification of the Myocardium for the Treatment of Cardiac Arrhythmias: Background, Current Results, and Future Possibilities. ACTA ACUST UNITED AC 1990. [DOI: 10.1007/978-1-4613-1489-9_24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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16
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Svenson RH, Littmann L, Gallagher JJ, Selle JG, Zimmern SH, Fedor JM, Colavita PG. Termination of ventricular tachycardia with epicardial laser photocoagulation: a clinical comparison with patients undergoing successful endocardial photocoagulation alone. J Am Coll Cardiol 1990; 15:163-70. [PMID: 2295728 DOI: 10.1016/0735-1097(90)90194-t] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Electrical activation-guided laser photocoagulation was used intraoperatively to terminate ventricular tachycardia in patients with ischemic heart disease. During ventricular tachycardia, laser irradiation was delivered to mapped sites with local diastolic activation. In 30 long-term survivors, 85 ventricular tachycardia configurations were terminated by ablation; 72 (84.7%) were terminated by endocardial photocoagulation. Thirteen (15.3%) required epicardial photocoagulation; however, these 13 ventricular tachycardias occurred in 10 (33%) of the 30 patients. An aneurysm was present in 70% of patients with successful endocardial photocoagulation, but in only 10% of patients requiring epicardial photocoagulation for at least one ventricular tachycardia configuration; 90% of all patients requiring epicardial laser photocoagulation had no aneurysm and had either a right or a left circumflex coronary artery-related infarction. In this group, epicardial activation data were similar to those described for ventricular tachycardia with an "endocardial" origin and included 1) delayed potentials during sinus rhythm, 2) presystolic or pandiastolic activation sequences during ventricular tachycardia, and 3) regions of block near the presumed region of reentry during ventricular tachycardia. This study suggests that the critical anatomic substrates supporting reentry in postinfarction ventricular tachycardia may occur at intramural or epicardial sites, particularly in patients with right or circumflex coronary artery-related infarction and no aneurysm.
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Affiliation(s)
- R H Svenson
- Sanger Clinic, Charlotte, North Carolina 28207
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Affiliation(s)
- G M Lawrie
- Department of Surgery, Baylor College of Medicine, Houston, Texas
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Comparison of early and late dimensions and arrhythmogenicity of cryolesions in the normothermic canine heart. J Thorac Cardiovasc Surg 1989. [DOI: 10.1016/s0022-5223(19)35341-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Caceres J, Akhtar M, Werner P, Jazayeri M, McKinnie J, Avitall B, Tchou P. Cryoablation of refractory sustained ventricular tachycardia due to coronary artery disease. Am J Cardiol 1989; 63:296-300. [PMID: 2913731 DOI: 10.1016/0002-9149(89)90334-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Thirty-nine patients with medically refractory sustained monomorphic ventricular tachycardia (VT) due to coronary artery disease underwent map-guided cryosurgery. Locations of prior myocardial infarctions had been inferior in 22, anterior in 16 and combined in 1. Mean age was 61 +/- 9 years and the mean number of drug trials per patient before surgery was 3.8 +/- 1.4. Intraoperative endocardial mapping induced 67 tachycardias in 35 patients. Each patient received 6 to 18 (11 +/- 3) endocardial cryothermic applications (15 mm, -60 degrees C, 2 minutes) at areas of earliest activation during VT. Encircling endocardial cryoablation was performed in 4 patients who had unsuccessful mapping. In addition, 11 patients had subendocardial resection of their well-demarcated septal scars as well as cryosurgery. There were 2 in-hospital deaths. At postoperative programmed ventricular stimulation, 28 of the 37 patients (76%) had no inducible or spontaneous VT before hospital discharge. Six patients (16%) with spontaneous or inducible VT had a single morphology and were controlled with antiarrhythmic drugs that had previously failed. Therefore, surgery alone or in combination with drugs was efficacious in 92% of the population surviving surgery. The remaining 3 patients (8%) received automatic implantable cardioverter defibrillators. No significant difference in surgical outcome was seen between patients who had cryosurgery alone and those who had subendocardial resection together with cryoablation. Mean left ventricular ejection fractions before and after surgery were 33 and 39%, respectively (p less than 0.01). Clinical follow-up ranged from 2 to 36 months (18 +/- 12). One patient died of heart failure and another underwent heart transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Caceres
- Electrophysiology Laboratory, Sinai Samaritan Medical Center, Milwaukee, Wisconsin 53233
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Cox JL, Rosenbloom M. Surgical treatment of ventricular arrhythmias. Ann Thorac Surg 1988; 46:598-600. [PMID: 3056299 DOI: 10.1016/s0003-4975(10)64713-3] [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: 01/03/2023]
Affiliation(s)
- J L Cox
- Department of Surgery, Barnes Hospital, Washington University School of Medicine, St. Louis, MO
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Abstract
Cryoablation is recognized as a useful modality for diagnostic mapping, as well as for permanent obliteration of arrhythmogenic foci. This technique has been used to eradicate irritable foci at the base of papillary muscles. We report a case of mitral valve dysfunction requiring valve replacement following cryoablation of the posterior papillary muscle. Based on this experience, we caution against extensive cryoablation of papillary muscle tissue because of the possibility of disrupting mitral valve function.
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Affiliation(s)
- W Piccione
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612-3864
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Cáceres J, Werner P, Jazayeri M, Akhtar M, Tchou P. Efficacy of cryosurgery alone for refractory monomorphic sustained ventricular tachycardia due to inferior wall infarction. J Am Coll Cardiol 1988; 11:1254-9. [PMID: 3366999 DOI: 10.1016/0735-1097(88)90289-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The efficacy of cryosurgery alone was evaluated in 15 patients with refractory monomorphic sustained ventricular tachycardias related to inferior wall infarction. Patients were 64 +/- 9 (SD) years old and had a mean left ventricular ejection fraction of 39.2 +/- 11.2%. Thirty different tachycardias were mapped with the origin localized to the septum or inferior wall in 20 (67%), near the mitral valve anulus in 6 (20%) and at the base of the posterior papillary muscle in 4 (13%) tachycardias. Endocardial cryoablation of these sites was performed with 6 to 13 (mean 9.2 +/- 1.8) cryolesions per heart. No mitral valve replacement was performed. There was one postoperative death as a result of sepsis. Cryoablation abolished inducible ventricular tachycardia in 11 patients. Of the other three patients, the tachycardia in two was controlled with a single antiarrhythmic agent that had previously failed to suppress inducible ventricular tachycardia. Thus, clinical success was obtained in 13 (93%) of 14 patients. The remaining patient received an automatic implantable cardioverter defibrillator. Ejection fraction remained unchanged or improved after surgery in 14 patients (93%). There have been no late deaths, recurrence of sustained ventricular tachycardia or significant mitral regurgitation during a mean follow-up period of 19 +/- 7 months. These results compare quite favorably with those previously reported for subendocardial resection alone, and indicate that cryosurgery is highly effective, does not result in deterioration of left ventricular function and preserves mitral valve competence when cryoablation of the posterior papillary muscle is necessary.
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Affiliation(s)
- J Cáceres
- Electrophysiology Laboratory, University of Wisconsin, Sinai Samaritan Medical Center, Milwaukee 53233
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Gallagher JJ, Selle JG, Svenson RH, Fedor JM, Zimmern SH, Sealy WC, Robicsek FR. Surgical treatment of arrhythmias. Am J Cardiol 1988; 61:27A-44A. [PMID: 3276124 DOI: 10.1016/0002-9149(88)90738-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Surgical treatment of arrhythmias is often more expeditious and more cost-effective in the long run than pharmacologic therapy. In the past, surgical treatment of arrhythmias has been reserved for patients with disabling paroxysmal or incessant tachycardia refractory to medical management, severe life-threatening arrhythmia or aborted episodes of sudden death. However, tachyarrhythmias that are refractory to pharmacologic therapy because of drug inefficacy, noncompliance or limiting side effects are not uncommon. Although nonpharmacologic treatment of arrhythmias carries with it a one-time period of higher risk (i.e., when the patient undergoes surgery), it is curative and often preferable to the uncertainty and possibly higher cumulative risk associated with medical management.
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Ostermeyer J, Borggrefe M, Breithardt G, Podczek A, Goldmann A, Schoenen JD, Kolvenbach R, Godehardt E, Kirklin JW, Blackstone EH, Bircks W. Direct operations for the management of life-threatening ischemic ventricular tachycardia. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36157-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Krafchek J, Lawrie GM, Roberts R, Magro SA, Wyndham CR. Surgical ablation of ventricular tachycardia: improved results with a map-directed regional approach. Circulation 1986; 73:1239-47. [PMID: 3698255 DOI: 10.1161/01.cir.73.6.1239] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To determine whether a regional approach to surgery for ventricular tachycardia would improve on the results of previously reported methods of endocardial resection, an analysis was performed of our surgical experience over a 5 year period. Of 46 consecutive patients operated on for recurrent sustained ventricular tachycardia or ventricular fibrillation, 39 patients with ischemic heart disease underwent subendocardial resection and/or cryoablation. The mean age of the patients was 61 +/- 8 (SD) years, the mean left ventricular ejection fraction was 32 +/- 11%, and the mean number of ineffective antiarrhythmic drugs was 3.8 +/- 1.2 per patient. In 35 of 39 patients in whom mapping data were obtainable, 56 (86%) tachycardias had earliest sites of activation in the left ventricle and nine (14%) had earliest sites in the right ventricle. Ten patients had 14 tachycardias (21%) mapped to areas outside visible dense scar. Of these 35 patients, 10 underwent localized subendocardial resection and 25 underwent a regional procedure in which all areas activated before the surface QRS during ventricular tachycardia were excised and/or cryoablated. In the operative survivors of electrophysiologically guided surgery, three of eight (38%) patients with the localized and one of 24 (4%) patients who underwent the regional procedure had recurrence of ventricular tachycardia during a follow-up period of 1 to 59 (mean 22 +/- 17) months (p = .04). The favorable outcome of regional surgery was not influenced by the presence of multiple morphologies in 54%, disparate sites of origin in 29%, or inferior wall foci in 46% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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