Results of nonguided subtotal endocardiectomy associated with left ventricular reconstruction in patients with ischemic ventricular arrhythmias

Surgical Ablation of Ventricular Tachycardia

Surgery for ventricular tachycardia (VT) is indicated in patients in whom pharmacotherapy or catheter ablation is ineffective or frequent VT attacks are not suppressed or with frequent activation of implantable cardioverter defibrillator. In ischemic VT, resection of fibrous endocardium combined with encircling cryothermia at the border between the infarcted and normal myocardium is performed. In surgery for VT associated with cardiomyopathy, close collaboration between the physician and surgeon is important and intraoperative mapping using electro-anatomic mapping system is helpful. In VT associated with cardiac tumors, cryothermia of the thinned subepicardial myocardium at the edge of the tumor is recommended in addition to resection of tumors.

Ablation therapy for ventricular arrhythmias in patients with LVAD: Multiple faces of an electrophysiological challenge

Left ventricular assist device implantation is a recognized treatment option for patients with advanced heart failure refractory to medical therapy and can be used both as bridge to transplantation and as destination therapy. The risk of ventricular arrhythmias is common after left ventricular assist device implantation and is influenced by pre-, peri and post-operative determinants. The management of ventricular arrhythmias can be a challenge when they become refractory to medication or to device therapy and their impact on prognosis can be detrimental despite the mechanical support. In this setting, catheter ablation is being increasingly recognized as a feasible option for patients in which standard therapeutic strategies fail, but also with preventive purpose. Catheter ablation is being increasingly considered for the management of ventricular arrhythmias in patients with left ventricular assist device despite complex clinical and technical peculiarities due to the characteristics of the mechanical support. Much conflicting data exist regarding the predictors of success of the procedure and the rate of recurrence. In this review we discuss the latest evidences regarding catheter ablation of ventricular arrhythmias in this subset of patients, focusing on clinical characteristics, arrhythmia etiology, technical aspects and postprocedural features which must be considered by the electrophysiologist.

Outcomes after surgical ventricular restoration for ischemic cardiomyopathy

OBJECTIVE

The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results.

METHODS

Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes.

RESULTS

One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated.

CONCLUSIONS

Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

Surgical procedure for targeting arrhythmogenic substrates in the treatment of ventricular tachycardia associated with cardiac tumors

BACKGROUND

Complete tumor resection is a standard strategy in the surgical treatment of ventricular tachycardia (VT) associated with cardiac tumors. Recently, an intraoperative electroanatomic mapping system (CARTO) has enabled surgeons to target the localized arrhythmogenic substrate for partial resection and/or cryoablation in nonresectable cardiac tumors.

OBJECTIVE

The purpose of this study was to evaluate the surgical procedures and late outcomes of the treatment of VT associated with cardiac tumors.

METHODS

We examined six patients (age 1-65 years) who had undergone surgical treatment of VT associated with cardiac tumors between 2010 and 2016. The 4 pathologies of the cardiac tumors were lipoma 2, fibroma 2, hemangioma 1, and lymphoma 1. Intraoperative epicardial mapping using CARTO was performed in 5 patients(80%). Surgical procedures and long-term outcomes were evaluated.

RESULTS

Arrhythmogenic substrates with abnormal electrograms, such as fractionated or late potential, were identified locally or circumferentially beside the tumor in every patient. Complete tumor resection with cryoablation was performed in 3 patients. Two patients underwent partial tumor resection with cryoablation. Cryoablation without tumor resection was performed in 1 patient. No mortality and morbidity occurred. Additional catheter ablation was required in 2 patients to treat occurrence of nonclinical VT and induction of clinical VT during hospital stay. Mean follow-up time was 90 ± 52.5 months. There was no recurrence of clinical VT.

CONCLUSION

The outcomes of surgical treatment of VT associated with cardiac tumors were excellent. Intraoperative CARTO mapping was beneficial to eliminate the VT substrates associated with nonresectable cardiac tumors.

Open chest epicardial and transapical endocardial substrate ablation for ventricular tachycardia with left ventricular aneurysm in a porcine model

BACKGROUND

Endo-epicardial radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) as a first-line strategy has been shown to improve outcomes. This study sought to evaluate the feasibility and validity of open-chest epicardial and transapical endocardial substrate ablation for VT with left ventricular aneurysm (LVA) applying to routine cardiac surgery.

METHODS

Porcine models of LVA with VT were developed and were divided into a study group (RFCA from the epicardium via direct-view and endocardium via transapical access) and a control group (endocardial RFCA via retrograde transaortic access). Substrate-based mapping and ablation targeting abnormal potentials were performed under thoracotomy. Outcomes, including procedural success and acute freedom from VT, were analysed.

RESULTS

Twenty-four of 35 (68.57%) acute myocardial infarction (AMI) pigs developed LVA with VT in a 6-week survival period and were randomly divided into a study group (n=12) and a control group (n=12). All animals in the study group successfully underwent endocardial mapping and ablation by transapical access. The scar size of the endocardium and the left ventricular chamber volume were similar in the two groups. Acute freedom from VT in the study group was remarkably superior to that in the control group (88.33% vs. 58.33%, p=0.04).

CONCLUSIONS

Combined, direct epicardial and transapical endocardial substrate mapping and ablation appeared to be feasible and effective for treating VT with LVA under thoracotomy.

Catheter ablation of ventricular tachycardia in a patient with a left endoventricular patch: a case report

Surgical resection of a left ventricular aneurysm in the setting of ventricular tachycardia (VT) was first described by Couch in 1959. The technique was further developed by Dor et al. with performance of endocardiectomy and complete myocardial revascularization. Despite an attempt to remove the arrhythmogenic substrate, however, recurrences of VT remain an issue. Furthermore, the surgical technique used entails limited access to the potential area of interest with regard to a percutaneous catheter ablation procedure. We present a case report of a 65-year-old man who was referred for catheter ablation due to recurrent episodes of VT. He had undergone a coronary artery bypass surgery 8 years previously. During surgery, resection of an apical thrombus and reconstruction of an apical aneurysm with a Fontan stitch and an endoventricular patch were performed. The mapping and ablation procedure was aided by intracardiac echocardiography. During mapping, the ablation catheter was noticed to enter the apical pouch from the inferoseptal border of the endoventricular patch. During the ablation procedure, one of the VTs was successfully ablated in the inferior aspect of the apical pouch. This report confirms that the arrhythmogenic substrate underneath an endoventricular patch may be accessed in some instances and that these complex catheter ablation procedures may benefit from the use of intracardiac echocardiography.

Ventricular fibrillation: triggers, mechanisms and therapies

Ventricular fibrillation (VF) is a common, life-threatening arrhythmia responsible for significant morbidity and mortality. Due to challenges in safely mapping VF, a comprehensive understanding of its mechanisms remains elusive. Recent findings have provided new insights into mechanisms that sustain early VF. Notably, the central role of electrical rotors and catheter-based ablation of VF rotor substrate have been recently reported. In this article, we will review data regarding four stages of VF: initiation, transition, maintenance and evolution. We will discuss the particular mechanisms for each stage and therapies targeting these mechanisms. We also examine inherited arrhythmia syndromes, including the mechanisms and therapies specific to each. We hope that the overview of VF outlined in this work will assist other investigators in designing future therapies to interrupt this life-threatening arrhythmia.

Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings

OBJECTIVE

The objective of this study was to evaluate the efficacy of a novel approach for endocardectomy during coronary artery bypass graft with surgical ventricular restoration in patients with postinfarction left ventricular aneurysm.

METHODS

One hundred sixty-eight patients underwent coronary artery bypass graft with surgical ventricular restoration from 2005 to 2011. Endocardectomy was performed as an integral part of surgical ventricular restoration for the prevention of ventricular tachycardia. The experimental group (surgical ventricular restoration-endocardectomy group; n = 74) underwent preoperative electrophysiologic study with electroanatomic left ventricular mapping. Radiofrequency ablation-induced markings were placed and were used later as guides for performing endocardectomy during coronary artery bypass graft with surgical ventricular restoration. The control group (surgical ventricular restoration group; n = 94) underwent surgical ventricular restoration without endocardectomy.

RESULTS

The 1-year mortality rates in the surgical ventricular restoration-endocardectomy and surgical ventricular restoration (control) groups were 5% and 13%, respectively. During the postoperative period, 3% of patients in the surgical ventricular restoration-endocardectomy group and 38% of patients in the surgical ventricular restoration group experienced ventricular tachycardia events (P < .05). Automatic implantable cardioverter-defibrillators were implanted in 11 patients in the surgical ventricular restoration group and in 1 patient of the surgical ventricular restoration-endocardectomy group for secondary prevention of sudden cardiac death.

CONCLUSIONS

When performed as an integral part of surgical ventricular restoration, endocardectomy was crucial in preventing postoperative ventricular tachycardia. Use of radiofrequency ablation-induced markings allowed clear visualization of the reentry zones for efficient endocardectomy during coronary artery bypass graft with surgical ventricular restoration, resulting in better patient outcomes.

Cryoablation during left ventricular assist device implantation reduces postoperative ventricular tachyarrhythmias

BACKGROUND

The number of patients undergoing implantation of a HeartMate II left ventricular assist device (LVAD; Thoratec Corporation, Pleasanton, Calif) is rising. Ventricular tachyarrhythmia (VA) after placement of the device is common, especially among patients with preoperative VA. We sought to determine whether intraoperative cryoablation in select patients reduces the incidence of postoperative VA.

METHODS

From January 2009 through September 2010, 50 consecutive patients undergoing implantation of the HeartMate II LVAD were examined. Fourteen of these patients had recurrent preoperative VA. Of those patients with recurrent VA, half underwent intraoperative cryoablation (Cryo: n = 7) and half did not (NoCryo: n = 7). Intraoperatively, patients underwent localized epicardial and endocardial cryoablation via LVAD ventriculotomy. Cryothermal lesions were created to connect scar to fixed anatomic borders in the region of clinical VA. Demographics, risk factors, intraoperative features, and outcomes were analyzed to investigate the feasibility of cryoablation.

RESULTS

Thirty-day mortality remained low (n = 1, 2%) among all LVAD recipients. There were no differences in risk factors between groups except that preoperative inotropes were less prevalent in Cryo patients (P = .09). Compared with NoCryo, the Cryo group had significantly decreased postoperative resource use and complications (P < .05). Recurrent postoperative VA did not develop in any of the Cryo patients (P = .02).

CONCLUSIONS

Postoperative VA can be minimized by preoperative risk assessment and intraoperative treatment. Localized cryoablation in select patients offers promising early feasibility when performed during HeartMate II LVAD implantation. Further prospective analysis is required to investigate this novel approach.

Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control

OBJECTIVES

Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR).

DESIGN

The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers.

RESULTS

Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia.

CONCLUSIONS

Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

Left ventricular restoration: how important is the surgical treatment of ischemic heart failure trial?

If the Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrates that surgical therapy is superior to medical therapy, early aggressive evaluation of coronary artery disease as a potentially correctable cause of new-onset heart failure would be the preferred strategy. This strategy could tremendously change the treatment of ischemic heart disease. Confirming the STICH revascularization hypothesis will dramatically increase the use of coronary artery bypass grafting among the millions of patients now being medically treated without evaluation for an ischemic cause.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: The Karolinska approach

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Improved Health-Related Quality of Life and Functional Status After Surgical Ventricular Restoration

BACKGROUND

Surgical ventricular restoration (SVR) has been shown to improve hemodynamics and survival among patients with coronary artery disease, left ventricular aneurysm, and heart failure. The aim of this study was to investigate functional status and health-related quality of life after SVR.

METHODS

Over a period of 2 years beginning in March 2003, 23 patients with left ventricular aneurysm and depressed left ventricular function were included in a prospective study. Functional status and quality of life was analyzed preoperatively, 6 months postoperatively, and at late follow-up by assessment of New York Heart Association (NYHA) functional class, 6-minute walk test, and the Medical Outcome Study 36-Item Short Form.

RESULTS

There was no early mortality. Before surgery, 17 patients (74%) were in NYHA class III to IV; and 6 months after SVR, 20 patients (87%) were in NYHA class I to II (p < 0.001). At late follow-up, (mean, 22 months postoperatively), all patients alive (n = 20) were in NYHA class I to II. Mean 6-minute walk distance increased by 41 meters (p = 0.06) at 6 months postoperatively and by 57 meters (p = 0.03) at late follow-up. Quality of life, assessed by the physical component summary score of the Medical Outcome Study 36-Item Short Form, improved significantly (p = 0.04) at 6 months postoperatively. A significant and clinically relevant improvement in both physical aspects (+25%, p < 0.001) and mental aspects (+37%, p = 0.003) of quality of life was found at late follow-up.

CONCLUSIONS

Functional status and quality of life improved 6 months after SVR, and the improvement was sustained at late follow-up almost 2 years after surgery.

Endoaneurysmorrhaphy and cryoablation for postinfarction left ventricular aneurysm with ventricular tachycardia

BACKGROUND

Early reperfusion in the acute phase of myocardial infarction and better medical treatment of consequent heart failure and tachyarrhythmia have decreased the incidence of massive myocardial infarction, left ventricular (LV) aneurysm and also postinfarction-sustained ventricular tachycardia (VT). However, for a number of patients, surgical ablation combined with aneurysm resection and myocardial revascularization remains a possible curative procedure. In this study, the efficacy of endoaneurysmorrhaphy and cryoablation was evaluated in patients with postinfarction LV aneurysm with VT.

METHODS

The medical records of 9 patients who underwent LV endoaneurysmorrhaphy and cryoablation for VT at Taipei Veterans General Hospital between January 1995 and August 2005 were reviewed retrospectively.

RESULTS

There were 8 men and 1 woman, with a mean age of 69.7 years (range, 52-77 years). Preoperative VT and LV aneurysm were found in all patients, who underwent extensive cryoablation at the transitional zone of scar and viable tissue without intraoperative mapping and LV remodeling with prosthetic patch. Associated procedure included coronary artery bypass grafting in 8 patients. During follow-up, no surgical or in hospital mortality were noted. There was 1 late sudden death at home 1.7 months after the operation. No recurrent VT was detected, and all patients showed improvement in New York Heart Association functional class (mean, 2.33 vs.1.67; p=0.025) and LV ejection fraction (mean, 26.3% vs.34.1%; p=0.021).

CONCLUSION

In patients suffering from postinfarction LV aneurysm complicated with VT, combining cryoablation and endoaneurysmorrhaphy offers good arrhythmia control and clinical outcome.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Left ventricular reconstruction as an alternative to heart transplantation: a case report

A 57-year-old man with dilated cardiomyopathy was referred to our institution to be assessed for heart transplantation. He had symptoms of severe heart failure and left ventricular dysfunction. We proposed surgical ventricular restoration (the Dor procedure) as an alternative to heart transplantation. The patient underwent successful surgery and an uneventful postoperative course. Pre- and postoperative investigations are presented. One year after surgery, the patient is in good clinical and functional condition. This case illustrates that surgical ventricular restoration can be an alternative to heart transplantation.

Surgery for Ventricular Tachycardia in Patients Undergoing Left Ventricular Reconstruction by the Dor Procedure

BACKGROUND

Surgical ventricular restoration (the Dor procedure) is an option in patients with coronary artery disease and postinfarction left ventricular aneurysm. The procedure can be extended to treat ventricular tachycardia (VT). The aim of this study was to evaluate the Dor procedure including VT surgery in our institution.

METHODS

From July 1997 to December 2003, 53 consecutive patients with left ventricular aneurysm and VT underwent surgical ventricular restoration including nonguided endocardiectomy and cryoablation. Twenty-four patients had at least one preoperative episode of spontaneous VT, of which 8 were survivors of sudden cardiac death. Twenty-nine patients had inducible-only VT. In 45 patients, who underwent preoperative programmed stimulation, sustained uniform VT could be initiated. Arrhythmia control was evaluated by programmed stimulation or analysis of events registered by implanted defibrillators and by review of patient's records.

RESULTS

Early mortality was 2 of 53 (3.8%). Mean follow-up was 3.7 years. At 1, 3, and 5 years overall actuarial survival was 94%, 80%, and 59%, respectively. Surgical success rate in patients with preoperative spontaneous VT was 91%. Inducible VT was found in 5 of 35 patients who underwent postoperative programmed stimulation. There was no arrhythmia-related late death and there was no loss to follow-up.

CONCLUSIONS

The Dor procedure including VT surgery is an effective treatment for postinfarction left ventricular aneurysm and VT and eliminates the need for an implantable defibrillator in most patients. Early and long-term results are good in terms of survival and arrhythmia control.

Ventricular arrhythmias after LV remodelling: surgical ventricular restoration or ICD?

Ventricular arrhythmias cause ~50% of deaths in remodeled ventricles after myocardial infarction, and the Multicenter Automatic Defibrillator Implantation Trial (MADIT II) showed that the Implantable Cardioverter Defibrillator (ICD) saved lives in high risk coronary patients with advanced left ventricular dysfunction. We studied 382 patients with remodeled hearts by preoperative Ventricular stimulation (PVS) to evaluate surgical ventricular restoration (SVR) that excludes scar and lower ventricular volume alters the early and late arrhythmia process without ICD utilization.

METHODS

Clinical and hemodynamic results before and after SVR in post-infarction patients, are compared to contrast spontaneous and/or inducible ventricular tachycardia to patients without arrhythmias. Study arrhythmia groups included: Spontaneous in 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia: Inducible in 105 patients without clinical ventricular arrhythmias but PVS inducible ventricular tachycardia; and No arrhythmias in 190 patients without spontaneous or PVS inducible ventricular tachycardia.

RESULTS

Preoperative LV end systolic volume index helped define preoperative arrythmia potential: Spontaneous > 120/m(2), inducible > 100 ml/m(2), and none < 100ml/m(2). Overall operative mortality rate was 7.6% (29/382). Sudden cardiac death rate was 2.5% causing 18.7% of all deaths. Surgical management reduced inducible ventricular tachycardia, from 41% preoperatively (144/352) to 8% (26/307) at early study, and 8% (14/177) one year later. Cardiac mortality was low at 5-years and not different between groups, despite use of only one late ICD device.

CONCLUSIONS

Favorable electrical success rate and low mortality always included volume reduction to interrupt functional re-entry circuits, but also added endocardiectomy, cryoablation, CABG and mitral repair when needed. Overall SVR findings show volume and shape alteration limits ventricular arrhythmias that impair prognosis, and suggests ICD devices are not needed.

Endoventricular Patch Reconstruction of Ischemic Failing Ventricle. A Single Center with 20 years Experience. Advantages of Magnetic Resonance Imaging Assessment

The left ventricular reconstruction (LVR) with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular aneurysm or asynergy after myocardial infarction. Scarred LV wall can be dyskinetic or akinetic according to the type of infarction (transmural or not), and the progressive dilatation of LV (remodeling) depends on the size of the asynergic scar. Assessment of this extension and of LV volume and performances, is easy and reliable by magnetic resonance (CMR). The surgical technique is based on the insertion inside the ventricle on contractile myocardium, of a circular patch restoring curvature and physiological volume, and allowing exclusion of asynergic non resectable regions. The ventricular reconstruction method also has other components that include coronary revascularization (almost always), mitral repair (if needed) and endocardectomy when spontaneous or inducible ventricular tachycardia (VT) are present. The experience of the authors (> 1100 cases) and results obtained by other Centers, allows proposal of this technique as a way to treat the ischemic failing ventricle.

Long-Term Outcomes After Cryoablation for Ventricular Tachycardia During Surgical Treatment of Anterior Ventricular Aneurysms

Intraoperative map-guided procedures have been widely advocated as the best surgical strategy for the treatment of ventricular tachycardia (VT), though favorable results have been reported with subendocardial resection without mapping. This study examined the very long-term results of encircling cryoablation without mapping during surgery for anterior left ventricular aneurysm complicated by VT. Between 1985 and 2003, this procedure was performed in 52 patients, 7 of whom (13.7%) were operated within 1 month of anterior myocardial infarction. Their mean age was 64.4 +/- 8.3 years and mean left ventricular ejection fraction was 31.7%+/- 9.5%. The overall hospital mortality was 1.9%. At 14 years, 86% of patients (95% CI: 75.4-96.6) were free from VT or sudden death. An implantable defibrillator was implanted in five patients (9.6%) during follow-up. The 14-year overall survival was 51.4% (95% CI: 33.8-72.4), and two patients (3.8%) underwent cardiac transplantation during follow-up. The main cause of late death was congestive heart failure in eight patients (40.0%). Favorable long-term results can be achieved with encircling cryoablation without mapping in patients undergoing surgery for anterior left ventricular aneurysm complicated by VT.

Changes in left ventricular volume and predictors of cardiac events after endoventricular circular patch plasty

OBJECTIVE

The aim of this study was to identify predictors of cardiac events after endoventricular circular patch plasty (Dor operation) by analyzing our experience with Dor operation.

METHODS

Thirty patients with left ventricular aneurysm and/or ischemic cardiomyopathy who underwent Dor operation were included in this study. Hemodynamic and clinical results were analyzed, and the predictors of cardiac events were examined.

RESULTS

Hospital mortality was 3.3%. Postoperative clinical status and left ventricular (LV) function in all survivors significantly improved. The survival rates at 1, 3, and 5 years after operation were 93%, 89% and 89%. The corresponding cardiac event-free rates were 75%, 67% and 49%. Pre- and postoperative LV function and volume did not differ significantly between patients with or without cardiac events. However, the proportion of reduced end-diastolic volume index (EDVI) (preoperative EDVI-postoperative EDVI) to preoperative EDVI was significantly higher in patients with cardiac events than in cardiac event-free patients. Postoperative LV volume re-increased in the cases with cardiac events during follow-up. Cox regression analysis confirmed that preoperative clinical premature ventricular contraction and end-systolic volume index (ESVI), postoperative EDVI, ESVI, and ejection fraction were independent predictors of late cardiac events. There was a significant positive correlation between preoperative ESVI and postoperative EDVI.

CONCLUSION

Though LV function significantly improved after Dor operation, LV reconstruction with excessive reduction can cause restarting LV remodeling and increasing mortality and morbidity. Therefore, LV reconstruction of appropriate sizes and shapes, considering the function of residual myocardium, has a significant effect on prognosis. It is highly reasonable to expect that preoperative ESVI can predict the optimal size of reconstructed left ventricle.

Cardiac Surgery for Arrhythmias

Cardiac arrhythmia surgery was initiated in 1968 with the first successful division of an accessory AV connection for the Wolff-Parkinson-White Syndrome. Subsequent surgical procedures included the left atrial isolation procedure and the right atrial isolation procedure for automatic atrial tachycardias, discrete cryosurgery of the AV node for AV nodal reentry tachycardia, the atrial transection procedure, corridor procedure and Maze procedure for atrial fibrillation, the right ventricular disconnection procedure for arrhythmogenic right ventricular tachycardia, the encircling endocardial ventriculotomy, subendocardial resection procedure, endocardial cryoablation, the Jatene procedure, and the Dor procedure for ischemic ventricular tachycardia. Because of monumental strides in the treatment of most refractory arrhythmias by endocardial catheter techniques during the past decade, the only remaining viable surgical procedures for cardiac arrhythmias are the Maze procedure for atrial fibrillation and the Dor procedure for ischemic ventricular tachycardia. Nevertheless, the 25-30 years of intense activity in the field of cardiac arrhythmia surgery provided the essential foundation for the development of these catheter techniques and represent one of the most exciting and productive eras in the history of medicine. In one short professional career, we have witnessed the birth of arrhythmia surgery, its adolescence as an "esoteric" specialty, its prime as an enlightening yet exhausting period, and finally its waning years as a source of knowledge and wisdom on which better methods of treatment have been founded. One could hardly ask for a more rewarding experience.

Cardiac Surgery for Arrhythmias

Cardiac arrhythmia surgery was initiated in 1968 with the first successful division of an accessory AV connection for the Wolff-Parkinson-White syndrome. Subsequent surgical procedures included the left atrial isolation procedure and right atrial isolation procedure for automatic atrial tachycardias, discrete cryosurgery of the AV node for AV nodal reentrant tachycardia, the atrial transection procedure, the corridor procedure, and the maze procedure for atrial fibrillation, the right ventricular disconnection procedure for arrhythmogenic right ventricular tachycardia, and the encircling endocardial ventriculotomy, subendocardial resection procedure, endocardial cryoablation, the Jatene procedure, and the Dor procedure for ischemic ventricular tachycardia. Because of monumental strides in the treatment of most refractory arrhythmias by endocardial catheter techniques during the past decade, the only remaining viable surgical procedures for cardiac arrhythmias are the maze procedure for atrial fibrillation and the Dor procedure for ischemic ventricular tachycardia. Nevertheless, the 25 to 30 years of intense activity in the field of cardiac arrhythmia surgery provided the essential foundation for the development of these catheter techniques and represent one of the most exciting and productive eras in the history of medicine. In one short professional career, we have witnessed the birth of arrhythmia surgery, its adolescence as an "esoteric" specialty, its prime as an enlightening yet exhausting period, and finally its waning years as a source of knowledge and wisdom upon which better methods of treatment have been founded. One could hardly ask for a more rewarding experience.

Surgical remodeling of left ventricle

In the future, we can certainly expect better assessment of myocardial wall, LV morphology, and performance, with careful approach and analysis of CMR allowing us to check exactly the morphology and volume performances of the LV, and chiefly the wall itself (Fig. 6). Perhaps it will be possible to have a hope of recovery for dilated but nonscarred myocardium, through a combination of currently existing surgical treatment (LVR + myocardial revascularization + mitral repair) and new techniques such as LVAD in appraisal, to help the nondiseased and tired myocardium, and suppress the immune or the autogenous hormonal reaction and let antagonist drugs be efficient. Analysis of some results published by the Berlin Heart Center in Berlin, Germany and others from Magdi Yacoub, MD (personal communication, 2002) showed improvement in LV wall thickness and contraction after months of left ventricular assistance, allowing weaning the idiopathic cardiomyopathy patient from assistance (bridge to recovery). Similar management may be possible in ischemic cardiomyopathy, where the LV wall is not uniformly diseased--one part is a scar and one part is dilated with living perfused myocardium. The synthesis of surgery (LVR) for the scarred area and medical treatment and mechanical support for the dilated portion can become the future method to treat severe end-stage ischemic congestive heart failure. The potential of adding cellular therapy to stimulate growth in the viable distended myocardium is perhaps a further promising complement of this treatment.

Transmyocardial laser revascularization and left ventricular reduction surgery affect ventricular arrhythmias and heart rate variability

BACKGROUND

Transmyocardial laser revascularization (TMLR) and left ventricular reduction by endoventricular patch plasty (LVR) are 2 new surgical procedures performed in patients with endstage coronary artery disease and left ventricular dilation/aneurysms, respectively. As these are performed in patients at high risk for sudden cardiac death and may interact with arrhythmogenesis, we assessed the influence of these procedures on incidence and severity of ventricular tachyarrhythmias and time-domain heart rate variability.

METHODS

Preoperative and one week postoperative 24-hour Holter recordings were performed in 37 patients undergoing TMLR (n = 23, CO2-laser technique) or LVR (n = 14).

RESULTS

TMLR patients received a mean of 27.2 +/- 9.2 laser channels. Postoperatively, the proportion of patients who underwent TMLR with spontaneous ventricular tachycardia (> or =4 repetitive ventricular beats) increased (0% vs 26%, P <.05), including one patient who died from documented ventricular fibrillation during monitoring. There was no correlation to the number and/or location of laser-induced channels or to perioperative CK levels. HRV parameters were not altered by TMLR. By contrast, LVR did not significantly influence ventricular tachyarrhythmia episodes but markedly depressed all major HRV parameters (SDNN 116.4 vs 61.8, RMSSD 35.2 vs 19.9, pNN50 14.5 vs 4.9, all P <.05).

CONCLUSIONS

Early after TMLR, there is evidence of an increased incidence of spontaneous ventricular tachycardia enhancing the risk for sudden cardiac death, while HRV remains unaffected. By contrast, LVR resulted in a marked reduction in HRV still present one week postoperatively, while no effect was observed on incidence and/or severity of spontaneous ventricular tachyarrhythmias.

Surgical ventricular restoration in patients with postinfarction coronary artery disease: effectiveness on spontaneous and inducible ventricular tachycardia

Surgical ventricular reconstruction (SVR) involves resection of scar, septal exclusion, cavity reduction by endoventricular patch, and complete coronary grafting. At the Cardiothoracic Centre of Monaco, ventricular stimulation (PVS) is performed before SVR, unless contraindicated. In patients with spontaneous and/or inducible ventricular arrhythmias, nonguided endocardiectomy and cryosurgery are added. We report clinical and hemodynamic results after SVR in postinfarction patients, to compare management of patients with spontaneous and/or inducible ventricular tachycardia, with those without arrhythmias. The 3 subsets were: Group A, 87 patients with clinical documented ventricular arrhythmias and inducible or not inducible ventricular tachycardia (Spontaneous); Group B, 105 patients without clinical ventricular arrhythmias but with inducible ventricular tachycardia at PVS (Inducible); and Group C, 190 patients without spontaneous arrhythmias and not inducible ventricular tachycardia at PVS (No arrhythmias). Overall surgical mortality rate was 7.6% (29 of 382). Sudden death mortality was only 18.7% of all deaths. Surgical management caused marked reduction of inducible ventricular tachycardia, from 144 of 352 inducible ventricular tachycardia before surgery (41%), to 26 of 307 (8%) at early study, and 14 of 177 (8%) one year later. Cardiac mortality was low at 5 years, and not different among groups; this indicates that the surgical procedure limits the ventricular arrhythmias that normally impair prognosis in postinfarction dilated cardiomyopathy. We believe the favorable electrical success rate and low mortality are not linked to one aspect of the surgical procedure, but to an integrated approach that relieves ischemia (coronary bypass graft), and reduces left ventricular volumes (SVR) to improve pump function, and nonguided endocardiectomy plus cryoablation, to interrupt functional reentry circuits.

Intermediate survival and predictors of death after surgical ventricular restoration

This study examined the effects of Dor procedure on long-term survival in patients with previous transmural anterior myocardial infarction who were referred to a single experienced center for left ventricular reconstruction by endoventricular patch-plasty repair. Our aim was to evaluate the impact of this procedure on long-term survival and to assess the ability of preoperative, perioperative, and postoperative variables to predict late survival. Major indications for surgery were left ventricular dysfunction, angina, ventricular arrhythmias, or a combination of the three; 20 patients underwent urgent cardiac surgery. The total group was 245 patients, with 8.1% hospital mortality, and 19 patients lost to follow-up [corrected]. The study group comprised 207 patients. Many pre- and postoperative clinical, hemodynamic, and functional variables, as well as operative parameters, were studied by univariate analysis. During a mean follow-up period of 39+/-19 months, 30 end points were observed, including 27 deaths and 3 heart transplants. Event-free survival was 98%+/-1% at 1 year, 95.8%+/-1.4% at 2 years, and 82.1%+/-3.3% at 5 years. Cox regression analysis showed preoperative New York Heart Association functional class, ejection fraction, end systolic volume index, and remote asynergy as independent predictors of mortality. The procedure has a favorable impact on 5-year survival. Independent predictors of late survival are the preoperative functional status and the left ventricular systolic function.

Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience

The first experience with endoventricular circular patch plasty (EVCPP) was reported in 1984 as a surgical method to rebuild left ventricular (LV) geometry made more spheric after myocardial infarction. The consequence is dilated ischemic cardiomyopathy. In anterior infarction, the free LV wall and septum are scarred and become dyskinetic or akinetic. The fundamental approach excludes the noncontractile (asynergy) and nonresectable regions to restore more normal size and shape. The current experience of our group in 2001, includes 1,011 patients, and confirmation of our results by others, including an international team. The basic components are LV reconstruction, revascularization, and mitral repair (when needed), which form an integrated method of surgical management. Endocardiectomy and cryoablation are used with spontaneous and inducible ventricular arrhythmias. This article reviews these results and summarizes 10 important points concerning the surgical treatment of ischemic dilated cardiomyopathy that may provide guidelines for the future. These data indicate EVCPP, and its variations, form the central theme in surgical treatment of congestive heart failure.

Effects of the Dor procedure on left ventricular dimension and shape and geometric correlates of mitral regurgitation one year after surgery

OBJECTIVES

In the present study we retrospectively analyzed ventriculographic data from symptomatic patients after myocardial infarction who underwent the Dor procedure (endoventricular circular patch plasty repair) to evaluate left ventricular shape 1 year after the operation and to analyze the geometric correlates of late mitral regurgitation.

METHODS

Forty-four patients with previous transmural anterior myocardial infarction comprised the study group. Left ventricular volumes, global left ventricular systolic and diastolic sphericity, the extent of wall motion abnormalities, and the presence and degree of mitral regurgitation were analyzed before and 1 year after operation.

RESULTS

Comparing preoperative diastole to systole within the cardiac cycle, left ventricular shape becomes more elliptical in systole than it was in diastole (eccentricity index closer to 1). The intervention leads to an increased diastolic sphericity, but for each cardiac cycle, the systolic shape is more elliptical relative to its diastolic counterpart in respect to basal conditions. Mitral regurgitation was detected after operations in 17 patients; 14 of them did not have mitral regurgitation before operations. Patients with late mitral regurgitation had greater preoperative volumes and more spherical chamber than did patients without late mitral regurgitation.

CONCLUSIONS

Despite a more spherical postoperative left ventricular chamber, systolic pump function improves after the Dor procedure, mainly for the improvement in inferior wall shortening. The presence of late mitral regurgitation is relatively frequent in this series of patients, and this emphasizes the importance of a more accurate quantitative evaluation of preoperative functional mitral regurgitation to repair the valve when appropriate. Geometric correlates of late mitral regurgitation appeared to be greater chamber sphericity and larger ventricular volumes preoperatively.

Long-term results of visually guided left ventricular reconstruction as single therapy to treat ventricular tachycardia associated with postinfarction anteroseptal aneurysm

INTRODUCTION

Postinfarction ventricular tachycardia (VT), anteroseptal aneurysm, and ventricular dysfunction are commonly associated and predict a poor long-term prognosis. Surgical left ventricular reconstruction, which includes double plication of the anterior and septal wall, can improve ventricular function. This article analyzes the long-term efficacy of such a procedure to control recurrence of VT in a group of 50 consecutive patients.

METHODS AND RESULTS

The study group consisted of 50 consecutive patients operated on between December 1986 and December 1994. The group comprised 44 men and 6 women. The mean age was 56+/-11 years. All patients had spontaneous VT following an anterior myocardial infarction. Twenty-five patients had two or more episodes of VT (eight presented as cardiac arrest, nine as syncope). Coronary artery disease was limited to the left anterior descending artery in 27 patients. An anteroseptal aneurysm was present in 49 patients. All patients had VT induced by programmed ventricular stimulation before surgery, and left ventricular reconstruction was performed without intraoperative mapping in all cases. Total mortality, VT recurrence, and sudden death rate were the endpoints of the study. In-hospital mortality was 8%. Postoperative left ventricular ejection fraction improved from 0.38 to 0.50 (P<0.05). Only two patients had postoperative inducible VT. Overall survival, VT recurrence rate, and sudden death rate were 73%, 12%, and 10%, respectively, after a median follow-up period of 6.25 years (0 to 8 years).

CONCLUSION

Visually guided left ventricular reconstruction with septal and anterior wall plicature can be utilized effectively to treat recurrent VT associated with postinfarction anteroseptal aneurysm.

Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars

BACKGROUND

Many believe that dyskinesia is the only predictor of favorable surgical outcome after large myocardial infarction and that akinetic scars do not recover well in patients with globally depressed ventricular function.

METHODS

This study evaluates clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n = 51) or large dyskinetic scar (n = 49) and depressed left ventricular function (ejection fraction <30%). Groups were comparable for symptoms, indication for operation, and delay from myocardial infarction. Heart failure was a major indication for operation in both groups. Coronary grafting was performed in 98% of patients: 10 had mitral valve repair or replacement, and 47 patients with preoperative ventricular arrhythmias had cryotherapy. In-hospital mortality was 12% (five patients in the akinetic group [10%] and seven in the dyskinetic group [14%]).

RESULTS

Results showed an early and late improvement in New York Heart Association functional class and ejection fraction (from 23% +/- 5% to 31% +/- 11% to 40% +/- 13% in akinetic patients and from 23% +/- 6% to 41% +/- 10% to 41% +/- 12% in dyskinetic patients). Ventricular tachycardia was reduced significantly in both groups early and late after the operation.

CONCLUSION

We conclude that in patients with either large akinetic or dyskinetic scar and severe left ventricular dysfunction, endoventricular circular patch plasty associated with coronary grafting and cryotherapy, when indicated, provides surviving patients with significant improvement in cardiac function. This approach can be considered as an alternative to heart transplantation in patients with severe left ventricular dysfunction.

Endoventricular patch plasties with septal exclusion for repair of ischemic left ventricle: technique, results and indications from a series of 781 cases

Most cases of left ventricular aneurysms undergo operation through resection of the exteriorized dyskinetic area with longitudinal suturing of the opening and this technique has been considered by cardiologists (Froehlich et al) to bring no improvement to the morphology and performance of the left ventricle. Some technical modifications have been adopted, such as the septal plicature (Cooley) or circular suturing of the opening (Jatene). Since 1984 our team has used an endoventricular patch, sutured over the contractile area and excluding the akinetic non-resectable scars, bringing a significant and calculable improvement to the left ventricular function. This technique of left ventricular reconstruction (LVR), called endoventricular circular patch plasty (EVCPP) has been already used on more than 750 patients (May 97). Clinical and echographic data for each case are completed by right catheterisation with measurement of the cardiac output, pulmonary arterial pressures (PAP) and programmed ventricular stimulation (PVS), in order to detect eventual ventricular tachycardia (IVT). During left heart catheterisation, the morphology of the left ventricle (LV) is studied on right and left anterior oblique incidences and the LV ejection fraction (EF) is checked globally (GEF) and especially in its contractile portion (CEF). After surgery, a hemodynamic study associated with a PVS, is carried out during the first post-operative month, and again after one year. Results were clinically satisfactory in more than 90% of cases (8.9% of NYHA III-IV), and in more than 90% of cases with ventricular arrhythmia with the hemodynamic persistent EF at one year, superior to the pre-operative CEF. Thus we have to propose the following indications: Elective: This ventricular reconstruction can be recommended for ventricular aneurysms or akinesias with angina, arrhythmias or attacks of cardiac insufficiency, when GEF > 30% and CEF > 40%. The operative mortality rate varies from 1,5 to 3%, which is better than allowing natural evolution. Mandatory: In emergency, when safe immediate circulatory assistance or a cardiac transplant is unavailable, LVR can give hope for survival to more than 80% of patients, whereas natural evolution is without hope. Finally the operative indication is uncertain in two contrasting circumstances: In asymptomatic patients when hemodynamic and angiographic examinations after myocardial infarction show left ventricular dyskinesia. If GEF is below 40% and CEF below 50%, it seems wise to propose LVR in order to prevent unfavourable evolution. In end-stage ischemic cardiomyopathies, if the EF is below 20%, CEF is below 30%, cardiac output is below 1.5 l, and the mean pulmonary pressure is above 25, then a cardiac transplant should be considered. EVCPP with septal exclusion is a safe technique and easily reproduced when associated with coronary revascularization as far as practicable, then EVCPP improves the ventricular function. When associated with sub-total endocardectomy, then EVCPP allows excellent control of VA.

Akinetic versus dyskinetic postinfarction scar: relation to surgical outcome in patients undergoing endoventricular circular patch plasty repair

OBJECTIVES

This retrospective study attempted to relate surgical outcome with the extent and type of preoperative wall motion asynergy in patients with postinfarction myocardial scar who underwent endoventricular circular patch plasty repair and associated coronary grafting.

BACKGROUND

Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic scar, and previous studies have reported that the absence of paradoxic systolic motion correlates with higher operative mortality and no improvement in pump function.

METHODS

Two hundred forty-five patients who underwent endoventricular circular patch plasty repair and associated coronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation. All had right and left cardiac catheterization. The centerline method was applied to preoperative right anterior oblique LV angiography to assess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening <2 SD from the normal mean value (extent of asynergy ([A%]).

RESULTS

The overall perioperative mortality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all the clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a higher perioperative mortality rate (12%) than patients with a small scar (2.2%). After the operation, the ejection fraction (EF) increased from 36 +/- 13% to 50 +/- 13% (mean +/- SD), and pulmonary pressures significantly decreased. End-diastolic volume decreased from 199 +/- 75 to 89 +/- 36 ml/m2. Patients with a large akinetic scar had the most severely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressive improvement in function (EF from 25 +/- 9% to 41 +/- 12%), not different from that observed with large dyskinetic scarring (EF from 26 +/- 7% to 46 +/- 11%).

CONCLUSIONS

Surgical outcome of endoventricular circular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence of dyskinesia. Patients with a large akinetic scar and severely depressed pump function benefit from a relatively simple surgical procedure previously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, and the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function.

Perioperative and long-term results with mapping-guided subendocardial resection and left ventricular endoaneurysmorrhaphy

BACKGROUND

Surgical ablation of the arrhythmogenic focus in patients with life-threatening ventricular tachyarrhythmias can be curative. However, the surgical techniques have been plagued by a high perioperative mortality rate (averaging approximately 12%). Reconstruction of the left ventricle may reduce mortality.

METHODS AND RESULTS

Reconstruction of the left ventricle with a pericardial patch, or endoaneurysmorrhaphy, was performed with mapping-guided subendocardial resection for recurrent ventricular tachycardia in 25 patients over a 5-year period. Postoperatively, electrophysiological studies were conducted to assess the results of surgery, which were further evaluated during long-term follow-up with survival analyses. The study included 25 patients, 60 +/- 9 years of age, with coronary artery disease, discrete left ventricle aneurysms, and malignant ventricular tacharrhythmias. Left ventricular ejection fraction was 24 +/- 6% preoperatively. Left ventricular endocardial mapping, endocardial resection, and endoaneurysmorrhaphy were performed in all patients. There was no operative or postoperative (30-day) mortality. Postoperative ventricular tachycardia was induced in 2 of the 25 patients (8%); left ventricular function increased to 32 +/- 9% (range, 19% to 52%). At a mean follow-up of 37 +/- 16 months (range, 6 to 65 months), there had been 6 deaths, including 1 sudden cardiac death, 2 congestive heart failure deaths, and 3 noncardiac deaths. Analysis of multiple variables failed to identify predictors of postoperative inducibility, sudden cardiac death, cardiac death, or total mortality.

CONCLUSIONS

Endoaneurysmorrhaphy with a pericardial patch combined with mapping-guided subendocardial resection frequently cures recurrent ventricular tachycardia with low operative mortality and improvement of ventricular function. Long-term follow-up demonstrates low sudden cardiac death rates.

Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle

This study reports hemodynamic, electrophysiologic, and clinical results in 171 patients (157 men and 14 women, mean age 57 +/- 8 years) 1 year after endoventricular circular patch repair and coronary grafting for postinfarction left ventricular dyskinetic or akinetic aneurysm. All patients had hemodynamic and electrophysiologic study before the operation and early and 1 year after the operation. The vast majority of aneurysms were anterior (n = 166), with a mean delay from infarction of 43 +/- 50 months. Fifty-two percent of patients were in New York Heart Association class III or IV, and preoperative ejection fraction was less than 40% in the majority of them (75%). Preoperative clinical ventricular tachycardia was present in 25 patients and was inducible in 59 patients. All patients had endoventricular circular patch repair with a synthetic (n = 99) or autologous patch (n = 72); 96% had associated coronary grafting with a mean number of bypass grafts of 1.9 +/- 0.9. Results at 1 year demonstrated a significant increase in ejection fraction (from 36% +/- 13% to 46% +/- 12% (p < 0.0001) and a significant reduction in ventricular volumes (end-diastolic volume index from 116 +/- 5 to 94 +/- 29 ml/m2 and end-systolic volume index from 77 +/- 45 to 53 +/- 25 ml/m2, p < 0.0001). New York Heart Association functional classification was significantly improved (2.6 +/- 0.9 vs 1.4 +/- 0.6, p < 0.0001) and ventricular tachycardias were almost suppressed (no documented clinical ventricular tachycardias and 8% incidence of inducible ventricular tachycardias after 1 year, chi 2 < 0.001). Patients who benefit most from the operation are those with more severe preoperative left ventricular dysfunction (i.e., ejection fraction < 30%), more frequent ventricular arrhythmias, and larger ventricular volumes. At regression analysis, critical disease of the right coronary artery was the only independent predictor of unsatisfactory pump improvement (as evaluated by postoperative increase of ejection fraction < 10 absolute points). In conclusion, in our large series of patients operated on by one surgical team between 1988 and 1993, who were studied hemodynamically both before and after the operation, endoventricular circular patch repair of left ventricular aneurysm associated with coronary grafting definitely improves left ventricular pump function and clinical status 1 year after the operation.