The surgical treatment of ventricular tachycardias

J Tnoaxc CARDIOVASC SURG 84:704-715, 1982

The surgical treatment of ventricular tachycardias Simple aneurysmectomy versus electrophysiologically guided procedures Between 1971 and 1982, 41 patients were operated upon for recurrent sustained ventricular tachycardia. All but three had severe coronary artery disease with a history of myocardial infarction. In 10 patients (Group I) simple aneurysmectomy with or without aorta-coronary bypass grafting was done. Thirty-one patients (Group II) had an electrophysiologically guided procedure, mainly partial or complete encircling endocardial ventriculotomy (EEV) at the earliest source of electrical activity during ventricular tachycardia. The results in the two groups indicate a clear superiority of electrophysiologically guided procedures over simple aneurysmectomy regarding early and late disappearance of tachycardiac rhythm problems (p = O.O/); the differences between the two groups in hospital mortality (p = 0.43) and long-term survival are not significant. We compared our data with results in 160 cases of simple aneurysmectomy and 224 cases of electrophysiologically guided operations recently published in the literature. This comparison confirms the higher efficiency of mapping-guided procedures in eradicating ventricular tachycardias. The improvements in hospital and long-term survival, again, are not significant.

Jorg Ostermeyer, M.D. (by invitation), Gunter Breithardt, M.D. (by invitation), Ralf Kolvenbach, M.D.* (by invitation), Martin Borggrefe, M.D. (by invitation), Ludger Seipel, M.D.** (by invitation), Hagen D. Schulte, M.D. (by invitation), and Wolfgang Bircks, M.D. (by invitation), Dusseldorf, Federal Republic of Germany Sponsored by John W. Kirklin, M.D., Birmingham, Ala.

Long-tenn medical treatment of patients with ventricular tachycardia and coronary artery disease is unsatisfactory. The extensive myocardial damage present in most patients with coronary artery disease and ventricular tachycardia makes it unlikely that drug therapy

**Presently Professor and Chairman, Division of Cardiology and Nephrology, Department of Medicine, University of Tiibingen, Tiibingen, Federal Republic of Germany.

will be the ultimate answer. I The best treatment is that which permanently inactivates the cardiac tissue responsible for initiating or maintaining ventricular tachycardia; the most elegant and intellectually appealing approach is the direct anatomic identification and surgical destruction of an arrhythmogenic tissue" or the interruption of the pathological pathways of a reentry circle. The basic concept of the latter approach goes back to Mines" (1914), who documented that a circulating wave of excitation in a ring of myocardial tissue could be discontinued by dividing the ring at some point. This technique was first applied clinically in numerous patients with the Wolff-Parkinson-White syndrome associated with tachycardiac rhythm disturbances. The evolution of our understanding of ventricular tachyarrhythmias and concepts of their surgical treatment can be divided into three periods. In 1934 Parade" documented the occurrence of ventricular tachycardia

704

0022-5223/82/110704+ 12$01.20/0 © 1982 The C. V. Mosby Co.

From the Departments of Cardio-Thoracic Surgery (Chirurgische Klinik und Poliklinik B) and Cardiology (Medizinische Klinik und Poliklinik B), University of Diisseldorf Medical Center, Diisseldorf, Federal Republic of Germany. Read at the Sixty-second Annual Meeting of The American Association for Thoracic Surgery, Phoenix, Ariz., May 3-5, 1982. Address for reprints: Jorg Ostermeyer, M.D., Chirurgische Universitiitsklinik B, Moorenstr. 5, D-4000 Diisseldorf, Federal Republic of Germany. *Present address: Augusta Krankenhaus, Department of Surgery, Diisseldorf, Federal Republic of Germany.

Volume 84

Ventricular tachycardias

NumberS November. 1982

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in patients with ventricular aneurysm. The first successful surgical correction for ventricular tachycardia was done by Dr. Charles Bailey of Philadelphia, Pennsylvania , in 1956 by means of simple aneurysmectomy (published by Couch " in 1959). The clinical efforts regarding electrophysiologically guided surgical approaches to these arrhythmias go back to stimuli of Fontaine, Guiraudon , and Frank " of Paris, France, published in 1974 and 1975. In the meantime, simultaneous to the refinement of intraoperative mapping techniques,":" two types of electrophysiologically guided operative procedures have been developed: complete or partial encircling endocardial incision to interrupt atypic al pathways of excitation 7. 21. 24-29 and ventricular endocardial excision of tissue formations with arrhythmogenic prop-

erties." : 3(}-34

To determine reliably the efficacy of the surgical treatment of recurrent sustained ventricular tachycardia, one must evaluate the role of these new approaches relative to the conventional technique of simple aneurysmectomy with or without aorta-coronary bypass grafting . Definitions Ventricular tachycardia. A ventricular tachycardia is an abnormal rhythm that arises in the ventricles. Electrocardiographically, it is an episode of 10 or more successive ectopic ventricular complexes.' The range

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Fla. 2. Bipolar epicardial signals Ci£PIIEPJ\IEPJ 2IEPJ3 ) from an area of arrhythmogenic tissue identified by earliest electrical activation during ventricular tachycardia . EKG . Electrocard iogram . of rates for ventricular tachycardia is quite wide, from approximately 40 to 285 beats/min;" The hemodynamic consequences include a decrease in cardiac output and systemic arterial hypotension .P" Sustained ventricular tachycardia. A sustained ventricular tachycardia is an episode that lasts longer than 30 seconds or that requires termination before that time . A nonsustained ventricular tachycardia is one that spontaneously term inates within 10 to 30 seconds;" Medical refractoriness of ventricular tachycardia. A ventricular tachycardia is defined as refractory to drug therapy on the basis of failure to respond to one or more antiarrhythmic agents ,2 proved by means of serial electrophysiological testing .37 The following drugs were tested either alone or in combination: disopyramide, mexiletine, propafenone, aprindine , amiodarone, beta adrenergic blocking drugs, and digitalis . Inducibility of a ventricular tachycardia. Our stimulation protocol during serial testing includes the

706 Ostermeyer et al.

introduction of single and double ventricular extrastimuli during a driven ventricular rhythm at rates that were increased from 120 beats/min in increments of 20 beats/min to a maximum of 200 beats/min. 37 A ventricular tachycardia is considered to be no longer inducible if no ventricular tachycardia occurs during premature single or double stimulation at the same basic driven rate and at a basic driven rate that is at least 20 beats/ min higher than during control conditions. Freedom from ventricular tachycardia. A patient is considered to be free of ventricular tachycardia clinically if he has no spontaneous episodes of tachyarrhythmias during his postoperative follow-up period, proved at least once by means of 24 hour electrocardiographic (ECG) monitoring. A patient is considered to be free of ventricular tachycardia electrophysiologically if he has no clinically significant rhythm disturbances and if he no longer has late ventricular potentialss'"" and stimulusinducible tachycardias at electrophysiological evaluation. Patients who are clinically free of ventricular tachycardia but who have high-rate tachycardia inducible by programmed premature stimulation have to be considered at risk of developing those arrhythmias spontaneously. They require the protection of antiarrhythmic drugs. Patients Since 1971, 41 patients with recurrent sustained ventricular tachycardia have been operated upon at our institution. Ten patients underwent simple left ventricular aneurysm resection with or without aorta-coronary bypass grafting between 1971 and 1978 (Group I). Thirty-one patients had an electrophysiologically guided approach after introduction of intraoperative mapping facilities in 1978 (Group II). Group I. This group comprised one woman and nine men. Nine of these 10 patients had severe coronary artery disease with a history of myocardial infarction. Four patients had single-, another four triple-, and one patient had double-vessel disease. The mean age at myocardial infarction was 47.4 ± 3.7* years, and all patients had an aneurysm at the left ventricular apex. All patients had life-threatening recurrent ventricular tachycardia refractory to drug therapy. The time interval between myocardial infarction and operation ranged from 2 weeks to 9 years (mean 22.4 ± 13 months). One 22-year-old man had intractable ventricular *Values are mean ± standard error of the mean throughout this article.

The Journal of Thoracic and Cardiovascular Surgery

tachycardia not related to coronary artery disease. The tachycardia was due to a left ventricular aneurysm of unknown origin. The mean age at operation of the entire group was 46.7 ± 3.6 years. The preoperative left ventricular end-diastolic pressures ranged from 10 to 35 mm Hg with a mean of 20.7 ± 4.4 mm Hg. All patients underwent simple left ventricular aneurysmectomy , and three had aorta-coronary bypass grafting as well. The procedures were performed with cardiopulmonary bypass (CPB), moderate hypothermia, and intermittent crossclamping ofthe aorta. The mean CPB time was 58.9 ± 7.6 minutes, and the lowest blood temperature was 28.1 0 ± 0.9 0 C. One patient from this group, a 60-year-old man, died on the first postoperative day secondary to low cardiac output. This patient had been operated upon 2 weeks after acute myocardial infarction under emergency conditions. The nine survivors have been reinvestigated by means of 24 hour ECG monitoring. Clinically, six of them still had spontaneous bursts of ventricular tachycardia, but with lower rates than preoperatively, which necessitated antiarrhythmic drug medication. Four patients died between 15 and 48 months (mean 29 ± 3.5) after operation, two of them suddenly, certainly because of arrhythmias. The five long-term survivors have been followed up for an average of 52 months. Included in the follow-up data are the latest reports from the family doctors. According to this information, three patients are free of ventricular tachycardia clinically and two patients are receiving antiarrhythmic drugs as before, now with beneficial results (Fig. 1). Group n. This group consisted of 31 patients, four women and 27 men. Twenty-nine patients had severe coronary artery disease with a history of myocardial infarction, five of whom had two known infarctions. Single-vessel disease was present in 10, double-vessel disease in eight, and triple-vessel disease in 11 patients. The mean age at the latest myocardial infarction was 51 ± 1.5 years, and 24 patients had a typical aneurysm at the left ventricular apex. Twelve patients had recurrent sustained ventricular tachycardia refractory to drug therapy, as proved by means of serial electrophysiological tests.s? The remaining patients had a combined indication for treatment of tachycardia, left ventricular aneurysm and coronary artery disease, and in these individuals the drug resistance of ventricular tachycardia was not tested ultimately. The time interval between myocardial infarction and operation ranged from 6 weeks to 11 years (mean 16.3 ± 5.4 months).

Volume 84

Ventricular tachycardias

Number 5 November. 1982

707

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Fig. 4. High-gainaveraged precordialelectrocardiographic recordingsbefore and after operation in a patient with recurrent ventricular tachycardia. Preoperatively, typical late potentials could be documented which disappeared after encircling endocardial ventriculotomy. Two men, 52 and 25 years old, had intractable recurrent sustained ventricular tachycardia not related to coronary artery disease. The first had a small aneurysm at the left ventricular posterior wall of unknown origin; the second had an infiltrating growing hamartoma in the left ventricular myocardium.

All 31 patients were studied electrophysiologically before operation. Thirty of them clearly exhibited the criteria for a reentrant mechanism.": 42-49 and the mean rate of tachycardia was 220 ± 7.3 beats/min. The majority of our patients had a severely impaired left ventricular function, the end-diastolic pressures rang-

708

The Journal of Thoracic and Cardiovascular Surgery

Ostermeyer et al,

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Fig. 5. Results in 31 patients with ventricular tachycardia (VT) operated upon after 1978 by means of an electrophysioiogically guided approach. STIM. Stimulation-inducible ventricular tachycardias. SPONT. Spontaneously occurring ventricular tachycardias. (For details see text) ing from 5 to 40 mm Hg with a mean of 18.6 ± 1.8 mmHg. The mean age at operation of the entire group was 5 1.9 ± 1.5 years. Intraoperatively, all patients were studied electrophysiologically by epicardial mapping; 28 (90%) had both epicardial and endocardial mapping. Our criteria for identification of the arrhythmogenic tissue are as follows: earliest electrical activation during ventricular tachycardia (Fig. 2) and/or late and fragmented ventricular potentials at sinus rhythm (Fig. 3). As a result of this electrophysiological information and the preoperative angiographic findings, 15 patients underwent encircling endocardial ventriculotomy (EEV), left ventricular aneurysmectomy, and aorta-coronary bypass grafting. Six patients had EEV and aneurysm resection, and three patients had EEV plus coronary bypass. In two patients we did an aneurysmectomy associated with bypass procedures, and two other patients had endocardial scar excision combined with coronary grafting. Finally, one patient each underwent aneurysmectomy, aorta-coronary bypass grafting, and subtotal tumor resection. Of the 23 patients with additional bypass procedures, 11 received one graft, seven patients two vein grafts, four three grafts, and one patient required four bypasses. Our preferred "antiarrhythmic procedure" was the EEV. Of the 24 patients with this particular incision,

11 had a complete and 13 a partial EEV (which means an incision encircling 25% to 75% of the ventricular circumference) in order to keep the incision as discrete as possible and to avoid injuries to the mitral valve papillary muscles or to the specialized conduction bundles. All operations were carried out with CPB, moderate hypothermia, and intermittent cross-clamping of the aorta. The mean time of extracorporeal circulation was 155.6 ± 9.8 minutes, this duration reflecting mainly the considerable demand of CPB time for the intraoperative mapping (30 to 45 minutes). The lowest blood temperature was 23.20 ± 0.7 0 C. One patient from this group could not be weaned from CPB and died intraoperatively. This patient had triple-vessel disease with a scarred left ventricular posterior wall and ventricular tachycardia with a rate of 240 beats/min. The operation was done electively at age of 60 years, and a complete EEV with double bypass grafting was performed. The 30 hospital survivors were restudied electrophysiologically about 4 weeks after operation. Twenty-three of them (77%) could be considered as free of ventricular tachycardia, that is, no spontaneous arrhythmias, no detectable late potentials during ECG signal-averaging (Fig. 4),38-40 and no stimulus-inducible tachycardia. Three additional patients were free of rhythm disturbances clinically, but tachycardia was in-

Volume 84

Ventricular tachycardias

Number 5 November, 1982

709

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ducible by means of programmed premature stimulation. The operation was considered to be a failure in four patients; they had inducible as well as spontaneous tachycardias which necessitated antiarrhythmic drugs before discharge from the hospital. The survivors have been followed for 1 to 45 months (mean 12.7 ± 2.1 months) postoperatively. Three late deaths occurred 4, 5, and 13 months after operation, respectively. These three patients, all women, had been free of arrhythmias early postoperatively. One of them had a relapse of tachycardia after occlusion of the three bypass grafts; another died of congestive heart failure; the cause of death in the third is unknown. The 27 long-term survivors have been restudied by 24 hour ECG monitoring or examined clinically, or both, partly in cooperation with the family doctors. Twenty of them could be classified as cured of their tachycardia at present (April, 1982). Of the other seven, six are being treated beneficially with drugs and one patient needed, in addition, an antiarrhythmic working pacemaker (Fig. 5). Comparison, Group I versus Group Il. A direct comparison of the results in Groups I and II indicates a

Table I. Comparison of survival and results in our patients with recurrent sustained ventricular tachycardia operated upon by simple aneurysmectomy or with electrophysiological guidance

I

No. of patients Hospital survival rate (%) Free of VT (%) Long-survival rate (%) Free of VT (%)

Group I

Group II

10 90 33*

31 97 77*

50 60t/30*

87 74t/65*

Legend: The data indicate a clear superiority of electrophysiologically guided operations over aneurysmectomy regarding early and late disappearance of ventricular tachycardia (p = 0.01). The improvements in hospital mortality as well as long-term survival are not significant. VT, Ventricular tachycardia. *Percent of hospital survival rate. tPercent of long-term survival rate. tPercent of all patients.

clear superiority of electrophysiologically guided operations over simple aneurysmectomy regarding early and late disappearance of tachycardiac rhythm problems. The improvements in hospital mortality as well as long-term survival have not been statistically sig-

The Journal of

7 10 Ostermeyer et al.

Thoracic and Cardiovascular Surgery

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nificant to date, The corresponding data are shown in Table I and Fig. 6. Discussion

In the past it became evident that, whether associated with coronary artery disease or not, ventricular tachycardia is initiated and maintained by a morphologic abnormality." 5, 7, 9, 23, 24, 50-57 The surgical task is to identify this tissue 6-9, 12-15. \6-2\. 23. 44, 51, 58 and to remove it reliably's- 41, 55. 56. 58-60 or to interrupt the electrical pathways originating from the arrhythmogenic area.26-28. 52. 6\ In this context, simple aneurysmectomy must be classified as a "blind" approach eradicating the arrhythmogenic tissue more or less fortuitously. In contrast, electrophysiological guidance by means of intraoperative activation sequence mapping reliably identifies the abnormal area and should improve the therapeutic efficiency and results, The certain problems associated with a direct comparison of simple aneurysmectomy and electrophysiologically guided procedures have been stressed recently by Mason, Stinson, and their co-workers ,2.62 analyzing the Stanford University series, and Harken, Horowitz, and Josephson'" of Philadelphia: 1. The control groups of patients are not treated concurrently; thus any comparison of the two techniques necessarily has to be retrospective and nonrandomized. 2. One group is smaller than the other, and the overall length of follow-up in the two groups is significantly different.

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Fig. 8. Results in 224 patients with recurrent sustained ventricular tachycardia (VT) operated upon during recent years with electrophysiological guidance in Philadelphia, Birmingham, Stanford, Hannover, Paris, Utrecht. and Diisseldorf).

3. Without any doubt, uncertainties remain regarding severity and medical responsivness of the arrhythmias. 4. The differences in results in the two groups can be explained in part by improved operative techniques and postoperative care. Despite these reservations, we think that this analysis provides some evidence that electrophysiologically guided operations may improve operative mortality, long-term survival, and early and late obliteration of tachycardiac rhythm problems compared with results obtained with conventional techniques. However, in order to draw valid conclusions, we have to put our results into the frame of published data from other sources, For this reason we collected from the literature 191 cases of simple aneurysmectomy published between 1959 and 1980. 5,60,63-85 Most of these papers are brief case reports dealing mainly with successful results, Because these data would promote faulty impressions regarding the efficiency of simple aneurysmectomy in the treatment of ventricular tachycardia, they have been excluded from our statistical evaluation, Only 160 cases from series of 10 or more patients, published between 1973 and 1980, have been accepted.P" 68. 69, 73. 77. 78-80 Looking at these 160 surgical patients (our own data included), we found 129 hospital survivors and 104 long-term survivors (Fig. 7).

Volume 84 Number 5 November, 1982

100 % 80 60

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Ventricular tachycardias

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Fig. 9. Hospital and long-term survival rates in patients with ventricular tachycardia operated upon with electrophysiologic guidance (E) (n = 224) and by simple left ventricular aneurysmectomy (A) (n = 160). No statistically significant difference could be documented.

Fig. 10. Therapeutic efficiency of electrophysiologically guided operation (E) (n = 224) and simple aneurysmectomy (A) (n = 60) on the basis of clinical disappearance of ventricular tachycardia after operation. The differences between the groups are highly significant (p < 0.005).

Of the hospital survivors, 75 patients are reported to be free of tachycardia, and 62 of the long-term survivors were cured of their arrhythmia. We must stress in this regard that the terms "long-term survival" and "free of ventricular tachycardia" are not defined in the same way in all of these communications. These results have been compared with the outcome of 224 patients (Fig. 8) operated upon with electrophysiological guidance during recent years in Philadelphia, Pennsylvania, 59 Birmingham, Alabama.V'" Stanford, California, 62 Hannover, Federal Republic of Germany.vt Paris, France.t" Utrecht, The Netherlands,:j: and by our group. From these institutions, 193 hospital survivors and 166 long-term survivors have been reported, and 129 of the long-term survivors could be classified as free of ventricular tachycardia clinically. According to the chi square test, the statistical differences among the groups are not significant regarding hospital and long-term survival (Fig. 9). In contrast (Fig. 10), the percentages of patients cured of ventricular tachycardia postoperatively are significantly different (p < 0.005). In analyzing these results, we have taken into account the reservations that must be considered in retro-

spective and nonrandomized studies using data from the literature; with certainly non-uniform reliability. We have concluded that the electrophysiologically guided procedures of endocardial excision and encircling endocardial incision provide a more efficient therapeutic approach to recurrent sustained ventricular tachycardia than the former technique of simple aneurysm resection. It remains questionable whether and in which dimensions these new techniques improve hospital and long-term survival in these patients. With this comparison, we do not comment on the question of whether encircling endocardial incision or endocardial excision can be carried out with similar success without mapping guidance.F

*Personal communication. A. L. Waldo. tPersonal communication, G. Frank. tPersonal communication. o. Alfieri.

REFERENCES 1 Wellens HJJ, Bar FWHM, Vanagt EJDM, Brugada P: Medical treatment of ventricular tachycardia. Considerations in the selection of patients for surgical treatment. Am J CardioI49:186-193, 1982 2 Mason JW, Stinson EB, Winkle RA, Oyer PE, Griffin JC, Ross DL: Relative efficacy of blind ventricular aneurysmectomy for the treatment of recurrent ventricular tachycardia. Am J Cardiol 49:241-248, 1982 3 Mines GR: On circulating excitations in heart muscles and their possible relation to tachycardia and fibrillation. Trans R Soc Can Section IV, 43-52, 1914 4 Parade GW: Aneurysmatische Elongationen des Herzens. Med Klin 30:1357-1359, 1934

The Journal of

7 1 2 Ostermeyer et al,

5 Couch OA: Cardiac aneurysm with ventricular tachycardia and subsequent excision of aneurysm. Circulation 20:251-253, 1959 6 Fontaine G, Guiraudon G, Frank R: La cartographie epicardiaque et Ie traitment chirurgical par simple ventriculotomie de certaines tachycardies ventriculaires rebelles par reentree. Arch Mal Coeur 68: 113-124, 1975 7 Bircks W, Ostermeyer J, Breithardt G, Seipel L: Chirurgische Moglichkeiten der Therapie tachykarder Arrhythmien. Verh Dtsch Ges Herz Kreislaufforsch 47:8086, 1981 8 Boineau JP, Cox JL: Rationale for a direct surgical approach to control ventricular arrhythmias. (Relation of specific intraoperative techniques to mechanism and location of arrhythmic circuit.) Am J Cardiol 49:381-396, 1982 9 Durrer D, Van Lier AAW, Buller J: Epicardial and intramural excitation in chronic myocardial infarction. Am Heart J 68:765-776, 1964 10 Gallagher 11: Surgical treatment of arrhythmias. Current status and future directions. Am J Cardiol 41: 1035-1044, 1978 II Gallagher 11, Cox JL: Status of surgery for ventricular tachycardia. Circulation 60: 1440-1442, 1979 12 Gallagher 11, Kasell J, Cox JL, Smith WM, Ideker RE, Smith WM: Techniques of intraoperative electrophysiologic mapping. Am J Cardiol 49:221-240, 1982 13 Horowitz LN, Harken AH, Kastor JA, Josephson ME: Ventricular resection guided by epicardial and endocardial mapping for treatment of recurrent ventricular tachycardia. N Engl J Med 302:589-593, 1980 14 Horowitz LN, Josephson ME, Harken AH: Epicardial and endocardial activation during sustained ventricular tachycardia. Circulation 61: 1227-1238, 1980 15 Josephson ME, Horowitz LN, Farshidi A, Spear JF, Kastor JA, Moore EN: Recurrent sustained ventricular tachycardia. 2. Endocardial mapping. Circulation 57:440-447, 1978 16 Kastor JA, Spear JF, Moore EN: Localization of ventricular irritability by epicardial mapping. Circulation 45: 952-964, 1972 17 Klein GJ, Ideker RE, Smith WM, Harrison LA, Kasell J, Wallace AG, Gallagher 11: Epicardial mapping of the onset of ventricular tachycardia initiated by programmed stimulation in the canine heart with chronic infarction. Circulation 60: 1375-1384, 1979 18 Ostermeyer J, Breithardt G, Kolvenbach R, Abendroth RR, Seipel L, Bircks W: Methode und Technik des intraoperativen Mapping. Z Kardiol 68:320-325, 1979 19 Ostermeyer J, Breithardt G, Kolvenbach R, Korfer R, Seipel L, Schulte HD, Bircks W: Intraoperative electrophysiologic mapping during cardiac surgery. Thorac Cardiovasc Surg 27:260-270, 1979 20 Spielman SR, Michelson EL, Horowitz LN, Spear JF, Moore EN: The limitations of epicardial mapping as a guide to the surgical therapy of ventricular tachycardia. Circulation 57:666-670, 1978

Thoracic and Cardiovascular Surgery

21 Waldo AL, Arciniegas JG, Klein H: Surgical treatment of life-threatening ventricular arrhythmias. The role of intraoperative mapping and consideration of the presently available surgical techniques. Progr Cardiovasc Dis 23:247-264, 1981 22 Wit AL, Allessie MA, Bonke FIM, Lammers W, Smeets J, Fenoglio JJ: Electrophysiologic mapping to determine the mechanism of experimental ventricular tachycardia initiated by premature impulses. Am J Cardiol 49: 166185, 1982 23 Wittig JR, Boineau JP: Surgical treatment of ventricular arrhythmias using epicardial, transmural and endocardial mapping. Ann Thorac Surg 20: 117-125, 1975 24 Frank G, Klein R, Lichtlen P, Borst HG: Direct surgical therapy of ventricular arrhythmias in coronary heart disease. Thorac Cardiovasc Surg 29:315-319, 1981 25 Frank G, Klein H, Lichtlen P, Borst HG: New surgical technique of endocardial incision in ventricular tachycardias in coronary heart disease. Circulation 64:Suppl 4:89, 1981 26 Guiraudon G, Fontaine G, Frank R, Escande G, Etievent P, Vignes R, Mattei MF, Cabrol A, Cabrol C: La ventriculotomie circulaire d 'exclusion. Arch Mal Coeur 71: 1255-1262, 1978 27 Guiraudon G, Fontaine G, Frank R, Escande G, Etievent P, Cabrol C: Encircling endocardial ventriculotomy. A new surgical treatment for life-threatening ventricular tachycardias resistant to medical treatment following myocardial infarction. Ann Thorac Surg 26:438-443, 1978 28 Guiraudon G, Fontaine G, Frank R, Grosgogeat Y, Cabrol C: Encircling endocardial ventriculotomy. Late follow-up results. Circulation 62:Suppl 3:320, 1980 29 Ostermeyer J, Breithardt G, Seipel L, Abendroth RR, Schulte HD, Bircks W: Tachycardiac rhythm disorders. J Cardiovasc Surg 22:457, 1981 30 Ward DE, Camm AJ: The surgery of cardiac arrhythmias. Hospital Update, July, 1979, pp 601-618 31 Harken AH: Horizons in electrical surgery. Ann Thorac Surg 32:425-426, 1981 32 Durrer D, Formijne P, Van Dam RT, Buller J, Van Lier AAW, Meyler FL: The electrocardiogram in normal and some abnormal conditions. Am Heart J 61:303-314, 1961 33 Moran JM, Talano JV, Euler D, Moran JF, Montoya A, Pifarre R: Refractory ventricular arrhythmia. The role of intraoperative electrophysiological study. Surgery 82:809-815, 1977 34 Graham A, Miller D, Stinson H, Daily M, Fogarty T, Harrison DC: Surgical treatment of refractory life-threatening ventricular tachycardia. Am J Cardiol 32:909-912, 1973 35 Waldo AL, MacLean WAH: Diagnosis and Treatment of Cardiac Arrhythmias Following Open Heart Surgery, Mount Kisco, N. Y., 1980, Futura Publishing Co., Inc. 36 Samet P: Hemodynamic sequelae of cardiac arrhythmias. Circulation 47: 399-407, 1973 37 Breithardt G, Seipel L, Abendroth RR, Loogen F: Serial

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Ventricular tachycardias

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electrophysiological testing of antiarrhythmic drug efficacy in patients with recurrent ventricular tachycardia. Eur Heart J 1: 11-24, 1980 Breithardt G, Becker R, Seipel L, Abendroth RR, Ostermeyer J: Non-invasive detection oflate potentials in man. A new marker for ventricular tachycardia. Eur Heart J 2: I-II, 1981 Breithardt G, Seipel L, Ostermeyer J, Karbenn U, Abendroth RR, Yeh HL, Bircks W: Effects of antiarrhythmic surgery on late ventricular potentials recorded by precordial signal averaging in patients with ventricular tachycardia. Am Heart JIM: 1982 Breithardt G, Borggrefe M, Karbenn U, Ostermeyer J, Seipel L, Abendroth RR, Yeh HL, Bircks W: Verhalten ventrikularer Spatpotentiale nach operativer Therapie ventrikularer Tachykardien. Z Kardiol 71:381-386, 1982 Simson MB, Spielman SR, Horowitz LN, Falcone RA, Harken HA, Josephson ME: Effects of surgery for control of ventricular tachycardia on late potentials. Circulation 64:Suppl 4:88, 1981 EI-Sherif N, Lazzara R, Hope RR, Scherlag BJ: Reentrant ventricular arrhythmias in the late myocardial infarction period. Circulation 56: 225-234, 1977 Josephson ME, Horowitz LN, Farshidi A, Kastor JA: Recurrent sustained ventricular tachycardia. I. Mechanisms. Circulation 57:431-440, 1978 Josephson ME, Horowitz LN, Farshidi A: Continuous local electrical activity. A mechanism of recurrent ventricular tachycardia. Circulation 57:659-665, 1978 Mason JW, Stinson EB, Winkle RA, Oyer PE: Mechanisms of ventricular tachycardia. Wide, complex ignorance. Am Heart J 102:1083-1087,1981 Seipel L, Ostermeyer J, Breithardt G, Bircks W: Chirurgische Therapie von Herzrhythmusstorungen. Verh Dtsch Ges Herz Kreislaufforsch 47:58-79, 1981 Vera Z, Mason DT: Reentry versus automaticity. Role in tachyarrhythmia genesis and antiarrhythmic therapy. Am Heart J 101:329-338, 1981 Waldo AL: Introduction and perspective. Am J Cardiol 49:163-165,1982 Wellens H11: Value and limitations of programmed electrical stimulation of the heart in the study and treatment of tachycardias. Circulation 57:845-853, 1978 Camm J, Ward DE, Cory-Pearce R, Rees GM, Spurrell RAJ: The successful cryosurgical treatment of paroxysmal ventricular tachycardia. Chest 75:621-624, 1979 Camm J, Ward DE, Spurrell RAJ, Rees GM: Cryothermal mapping and cryoablation in the treatment of refractory cardiac arrhythmias. Circulation 62:67-74, 1980 Fontaine G, Guiraudon G, Frank R, Fillette F, Cabrol C, Grosgogeat Y: Surgical management of ventricular tachycardia unrelated to myocardial ischemia or infarction. Am J Cardiol 49:397-410, 1982 Gallagher 11, Oldham HN, Wallace AG, Peter RH, Kasell J: Ventricular aneurysm with ventricular tachycardia. Am J Cardiol 35:696-700, 1975 Gallagher 11, Anderson RW, Kasell J, Rice JR, Pritchett

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ELC, Gault JH, Harrison L, Wallace AG: Cryoablation of drug-resistant ventricular tachycardia in a patient with a variant of scleroderma. Circulation 57: 190-197, 1978 Harken AH, Horowitz LN, Josephson ME: Endocardial excision guided by ventricular mapping in the surgical treatment of ventricular tachycardia. (abstr). Am J Cardiol 43:401, 1979 Josephson ME, Harken AH, Horowitz LN: Endocardial excision. A new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation 60: 14301439, 1979 Kehoe R, Moran J, Loeb J, Sanders J, Lesch M, Michaelis L: Visually directed versus electrically directed endocardial resection in recurrent ventricular tachycardia. Circulation 64:Suppl 4:89, 1981 Harken AH, Horowitz LN, Josephson ME: The surgical treatment of ventricular tachycardia. Ann Thorac Surg 30:499-508, 1980 Josephson ME, Harken AH, Horowitz LN: Long term results of endocardial resection for sustained ventricular tachycardia. Circulation 64:Suppl 4:203, 1981 Harken AH, Horowitz LN, Josephson ME: Comparison of standard aneurysmectomy and aneurysmectomy with directed endocardial resection for the treatment of recurrent sustained ventricular tachycardia. J THoRAc CARDIOVASC SURG 80:527-534, 1980 Guiraudon G, Fontaine G, Frank R, Leandri R, Barra J, Cabrol C: Surgical treatment of ventricular tachycardia guided by ventricular mapping in 23 patients without coronary artery disease. Ann Thorac Surg 32:439-450, 1981 Mason JW, Stinson EB: Comparison of efficacy of mapguided to blind myocardial resection for recurrent ventricular tachycardia. Circulation 62:Suppl 3:263, 1980 Barry WH, Alderman EL, Daily PO, Harrison DC: Diagnosis and treatment of a case of recurrent ventricular tachycardia. Am Heart J 84:235-241, 1972 Basta LL, Takeshita A, Theilen EO, Ehrenhaft JL: Aneurysmectomy in treatment of ventricular and supraventricular tachyarrhythmias in patients with postinfarction and traumatic ventricular aneurysms. Am J Cardiol 32:693699, 1973 Bett JHN, Cooper E, Mushin G, Saltups A, Stafford G: Ventricular aneurysmectomy for recurrent tachyarrhythmias. Aust NZ J Med 4:253-255, 1974 Harrison DC, Buda AJ, Stinson EB: Surgery for ventricular arrhythmias, Management of Ventricular Tachycardia. Role of Mexitiline, E Sandoe, DG Julian, JW Bell, eds., Amsterdam-Oxford, 1978, Excerpta Medica Hunt D, Sloman G, Westlake G: Ventricular aneurysmectomy for recurrent ventricular tachycardia. Br Heart J 31:264-266, 1969 Kenaan G, Mendez AM, Zubiate P, Gray R, Kay JH: Surgery for ventricular tachycardia unresponsive to medical treatment. Chest 64:574-578, 1973 Klein H, Bethge KP, Frank G, Borst HG, Lichtlen P: Das Verhalten ventrikularer Arrhythmien nach Aneurysmektomie. Z Kardiol 68: 10-16, 1979

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70 Kluge TH, Ullal SR, Hill JD, Kerth WJ, Gerbode F: Dyskinesia and aneurysm of the left ventricle. Surgical experience in 36 patients. J Cardiovasc Surg 12:273-280, 1971 71 Kremer R, Chalant C, Ponlot R, Lavenne F: Tachycardie ventricu1aire recidivante gueri par resection d 'un aneurisme parietal du ventricular gauche. Acta Cardiol (Brux) 24:523-529, 1969 72 Liotta D, Ferrari H, Pisanu A, Pujadas G, Oliveri R, Donato 0: Medically uncontrollable recurrent ventricular tachyarrhythmia in association with ventricular aneurysm. Am J Cardiol 33:693-694, 1974 73 Loop FE, Effler DB, Navia JA, Sheldon WC, Groves LK: Aneurysms of the left ventricle. Ann Surg 178:399-404, 1973 74 Lull RJ, Dunn BE, Gregoratos G, Cox WA, Fisher GW: Ventricular aneurysm due to cardiac sarcoidosis with surgical cure of refractory ventricular tachycardia. Am J Cardiol 30: 282- 287, 1972 75 Magidson 0: Resection of postmyocardial infarction ventricular aneurysms. Chest 56:211-218, 1969 76 Maloy WC, Arrantis JE, Sowell BF, Hendrix GH: Left ventricular aneurysm of uncertain etiology with recurrent ventricular arrhythmias. N Engl J Med 285:662-663, 1971 77 Mason, JW, Buda AJ, Stinson EB, Harrison DC: Surgical therapy of ventricular tachycardia in ischemic heart disease using conventional techniques, Medical and Surgical Management of Tachyarrhythmias, W Bircks, F Loogen, HD Schulte, L Seipel, eds., Berlin-Heidelberg-New York, 1980, Springer Verlag 78 Mundth ED, Buckley MJ, DeSanctis RW, Daggett WM, Austen WG: Surgical treatment of ventricular irritability. J THoRAc CARDIOVASC SURG 66:943-951, 1973 79 Ricks WB, Winkle RA, Shumway NE, Harrison DC: Surgical management of life-threatening ventricular arrhythmias in patients with coronary artery disease. Circulation 56: 38-42, 1977 80 Sami M, Chaitman BR, Bourassa MG, Charpin D, Chabot M: Long term follow up of aneurysmectomy for recurrent ventricular tachycardia or fibrillation. Am Heart J 96:303-308, 1978 81 Schlesinger Z, Lieberman Y, Neufeld HN: Ventricular aneurysmectomy for severe rhythm disturbances. J THoRAc CARDIOVASC SURG 6:602-604, 1971 82 Schulte HD, Bircks W, Herzer JA, Neuhaus KL, Rivas-Martin R, Seipel L: Therapie lebensbedrohlicher Herzrhythrnusstorungen durch Resektion von Herzwandaneurysmen oder Divertikeln. Z Kardiol (Suppl 4), 60, 1977 83 Third GS, Blakemore WS, Zinsser HF: Ventricular aneurysmectomy for treatment of recurrent ventricular tachycardia. Am J Cardiol 27:690-694, 1971 84 Wardekar A, Son B, Gosaynie CD, Bercu B: Recurrent ventricular tachycardia successfully treated by excision of ventricular aneurysm. Chest 62:505-508, 1972 85 Welch TG, Fontana ME, Vasko JS: Aneurysmectomy for

recurrent ventricular tachyarrhythmias. Am Heart J 85:685-688, 1973 86 Arciniegas JG, Klein H, Karp B, Kouchoukos NT, James TN, Kirklin JW, Waldo A: Surgical treatment of lifethreatening ventricular tachyarrhythmias. Circulation 62: Suppl 3:42, 1980

Discussion DR. HANS G. BORST Hannover, Federal Republic of Germany

1 would like to congratulate the Dusseldorf group for their results, particularly in regard to early mortality. Our experience is very much in agreement with their findings both in terms of the nondirected and the directed types of operation for ventricular tachycardia. During the years 197 I to 1979 we performed 15 aneurysmectomies for the dominant indication of ventricular tachycardia. There was improvement in only three of these patients, but there was a substantial mortality both early and late. We therefore concluded that successful suppression of ventricular tachycardia by aneurysmectomy without electrophysiological guidance is a matter of chance. Since that time we have operated upon 22 patients with the aid of electrophysiological guidance and have noted a certain separation of the patients with regard to early survival. In patients having a substantial aneurysm, good remaining ventricular function, and easily treated coronary disease, the mortality was low. One of 15 such patients died. Conversely, among seven patients who had a small aneurysm or no aneurysm, very poor ventricular function, and diffuse coronary disease, usually not amenable to coronary bypass, three died. In our eyes, the dilemma really is how far one can extend the indication for operation. Our cardiologists tend to present many patients with end stage disease, and we have a hard time deciding whether or not we should operate. I have three questions for Dr. Ostermeyer. First, do you select your patients and if so what are your criteria? The second question relates to the long bypass times that were reported. Do you think a mean bypass period of 150 minutes is acceptable? We would be worried about this long period. I believe that epicardial and endocardial mapping should be limited to 20 or 30 minutes, whereby the epicardial procedure appears of lesser importance. Third, Dr. Ostermeyer, what surgical treatment was used in the last three patients in the second group? DR. JOHN M. MORAN Chicago, Ill.

From the beginning of our experience with endocardial resection at Northwestern University, we have consistently done what we refer to as extended endocardial resection-the removal of all visible endocardial scar, aided by the findings of intraoperative mapping. We do this because at least half of our patients have two or more tachycardic morphologies, all of which mayor may not be inducible at operation; intraoperative mapping is not always successful in our hands,

Volume 84 Number 5 November, 1982

often because of degeneration to fibrillation; and, finally, we are concerned that scar left behind at operation will in some patients eventually result in a late postoperative recurrence of arrhythmia. At the present time we have performed 50 extended endocardial resections in patients with both recurrent ventricular tachycardia and "sudden death" resulting from ventricular fibrillation. There are 45 survivors with follow-up periods ranging from 3 to 42 months (mean 15 months). All are in significantly improved conditions, the great majority being arrhythmia free without the need for antiarrhythmic drugs. Only four patients require drug therapy. I would like to ask Dr. Ostermeyer about postoperative ventricular function in his patients. I have great reservations about the encircling incision. Some recent experimental evidence from Duke University has documented a loss of compliance, indeed infarction, in muscle distal to such incisions. Also, have you had any experience with patients whose arrhythmia problem is characterized by ventricular fibrillation rather than recurrent tachycardia? DR. 0 S T E R M EYE R (Closing) I thank the discussers for their remarks and stimuli, and I am not aware of major disagreements at the present time. We select our patients for operation mainly on the basis of the intractability of their ventricular tachycardia. In addition, of course, we have to consider the condition of the coronary artery system and the significance of a left ventricular aneurysm. Up to now no patient has been rejected because of severely impaired hemodynamics or other critical aspects in the disease. In those patients mentioned by Professor Borst, who did

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not undergo a specific antiarrhythmic incision or excision, the mapping data did not yield clear information for identification of a circum script area of arrhythmogenic tissue. However, the indication for operation was the same as in the other cases, and for this reason we do not see any justification for excluding these patients from our series. Indeed, our intraoperative mapping studies take a long time and prolong the CPB times significantly. A routine mapping investigation in our hospital includes epicardial mapping (75 recording points) during sinus rhythm and ventricular tachycardia as well as left ventricular endocardial mapping (12 to 36 recording positions) during sinus rhythm and ventricular tachycardia. Usually the epicardial ventricular tachycardia mapping and the endocardial mapping require normothermic CPB perfusion. We consider this information extremely useful, as it improves the efficiency of the operation. We have never been able to do the mapping within 20 minutes. Regarding postoperative ventricular function, we can only present clinical data. Two of the long-term survivors regressed to the next worse New York Heart Association class; the majority of the remaining patients improved by one NYHA class. Fortunately, I cannot comment on the question concerning potential reasons for a high hospital mortality because we do not have the corresponding clinical material. In conclusion, there are encouraging indications that patients with medically intractable threatening ventricular tachycardia of the reentry type, with or without coronary artery disease, can be treated successfully by operation.