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Right arrow Electrophysiology - arrhythmias

Eur J Cardiothorac Surg 2004;26:323-329
© 2004 Elsevier Science NL

Surgical ablation of post-infarction ventricular tachycardia guided by mapping in sinus rhythm: long term results

Jan Pirka, Jan Bytesnikb, Josef Kautznerb, Petr Peichlb, Vlastimil Vancurab*, Katerina Lefflerovab, Ivo Skalskya, Vladimir Vinduskaa

a Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
b Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic

Received 10 October 2003; received in revised form 30 March 2004; accepted 31 March 2004.

* Corresponding author. Tel.: +420-60346-8697; fax: +420-24171-7669
e-mail: vlastimil.vancura{at}medicon.cz


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A. Conference...
 References
 
Objective: Some patients after myocardial infarction have an increased risk of malignant ventricular tachyarrhythmias (VTA) or sudden cardiac death. The aim of the study was to evaluate long-term results of surgical ablation of an arrhythmogenic substrate guided by simplified intraoperative mapping of pathological ventricular electrograms during sinus rhythm. Methods: The study population consisted of 77 patients (9 women; mean age 62.4±8.5 years) with previous Q-wave myocardial infarction and at least one documented episode of sustained VT/VF more than one month after the last infarction. The left ventricular ejection fraction was 31.3±8.8%. All but eight patients had clinical indication for concomitant coronary artery bypass surgery. All underwent preoperative electrophysiologic study. Intraoperative epicardial and endocardial mapping during sinus rhythm was performed using a multielectrode with 16 bipolar electrodes in combination with a multichannel recording system. Myocardial regions revealing fractionated, low amplitude signals lasting ≥130 ms were surgically excised or cryoablated. All surviving patients were restudied within one to two weeks after surgery using identical programmed electrical stimulation protocol. Results: Five (6.5%) patients died in the perioperative (30-days) period. In the remaining cohort, inducibility of any sustained VTA after surgical procedure was observed in 21 subjects (29.2%). An implantable cardioverter-defibrillator (ICD) was implanted in these patients. Recurrence of sustained VTA was documented during follow-up period in two patients who were noninducible after the surgery (at the month 10 and 22, respectively), and both received ICD as well. No patient died of sudden cardiac death. In 14 ICD patients, no significant VTA was documented during the mean follow-up of 37.3±23.2 months. Altogether, 61 from the 72 patients surviving the surgery (84.7%) remained free of spontaneous recurrences of VTA during the follow-up. Conclusions: Surgical ablation of an arrhythmogenic substrate guided by simplified intraoperative mapping in normothermic heart during sinus rhythm appears to be both safe and efficacious procedure that prevents recurrences of VTA in a substantial proportion of patients.

Key Words: Sudden cardiac death • Ventricular tachycardia • Ventricular fibrillation • Implantable cardioverter-defibrillator • Surgical ablation • Cardiac mapping


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A. Conference...
 References
 
Survivors of myocardial infarction are at risk of developing malignant ventricular tachyarrhythmias (VTA) that reflect the presence of an arrhythmogenic substrate within the myocardium. The substrate is usually located in the regions bordering infarcted areas where fibrous tissue interdigitates with bundles of viable myocardium. In such regions, abnormalities of impulse conduction and/or refractoriness prerequisite for reentrant VTA may occur [1,2]. At present, implantable cardioverter-defibrillator (ICD) has become the mainstay for prophylactic treatment of patients with spontaneous episodes of VTA (i.e. secondary prophylaxis of sudden cardiac death) [3]. Despite high efficacy of ICD in termination of VTA, the device does not prevent further recurrences of VTA and may be even proarrhythmic in some cases. In this respect, surgical ablative techniques carry a substantial potential to prevent and possibly cure substrate-related VTA.

Over a period of the last two decades, electrophysiologically guided surgery of post-infarction VTAs has evolved as one of the viable treatment modalities. Sophisticated mapping techniques allow rapid analysis of the arrhythmogenic substrate and its precise location [4,5]. Excision of the scarred myocardium in subendocardial location has been used as the most useful surgical approach. It has been shown to prevent clinical recurrences of VTA in approximately 90% of patients, despite postoperative inducibility of VTA reaching 20–30%. However, previous series have been accompanied by rather high perioperative mortality of 5–30% [6–9].

To minimize mortality and maximize the benefit, surgical technique should be a compromise between the preservation of cardiac function and neutralization of the substrate. Consequently, the modern principle of surgical treatment involves cryoablation or excision of a scar tissue as well as revascularization and left ventricular aneurysmectomy with remodelling when indicated. The extent of the mapping and surgery should be therefore tailored to an individual patient. The aim of this study was to evaluate long-term results of surgical ablation of post-infarction arrhythmogenic substrate guided by simplified intraoperative mapping in sinus rhythm.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusions
 Appendix A. Conference...
 References
 
The study population included 77 patients (9 women; mean age 62.4±8.5 years, range 34–77) who underwent VTA surgery between October 1987 and October 2002 at Institute for Clinical and Experimental Medicine, Prague. All reviewed patients had previous Q-wave myocardial infarction and at least one documented episode of sustained VT/VF which occurred 1 month or later after the last infarction. None of these arrhythmias were attributed to reversible cause. The location of myocardial infarction was anterior in 33, inferior in 25, posterior in 10, lateral in 4 and combination of different sites in 5 patients, respectively. Basic clinical characteristics are listed in Table 1.


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  		Table 1. Patient characteristics (N=77)

 
2.1. Preoperative evaluation
As a part of clinical work-up, all patients underwent coronary angiography. There was clinical indication for coronary artery bypass surgery in all but 8 of them. Those 8 remaining subjects had a history of recurrent paroxysms of monomorphic VTA resistant to antiarrhythmic therapy and presented with a distinct aneurysm of the left ventricle. Preoperative electrophysiology study consisting of programmed electrical stimulation (PES) from two right ventricular sites that included pacing at two basic cycle lengths 600 and 400 ms and PES with up to three extrastimuli was performed in all patients. Sustained monomorphic or polymorphic VT or ventricular flutter/fibrillation were induced as indicated in Table 1.

2.2. Late potential analysis
A pilot series of 23 consecutive patients underwent both preoperatively and postoperatively signal-averaged ECG recording (MAC 15, Marquette, Milwaukee, WI, USA). Time-domain analysis was performed with a noise level below 0.6 µV and filter setting at 45–250 Hz.

2.3. Surgical technique
The operation was performed through a median sternotomy. Epicardial mapping was used in all patients after cannulation for cardiopulmonary bypass and normothermic perfusion. The purpose-built, multielectrode array probe with 16 bipolar electrodes (interelectrode spacing 2 mm, the distance between individual dipoles 8 mm) and the multichannel recording system (ICA 16, HLS Medical Electronic Prague, Czech Republic or CardioLab 4.3, Prucka Engineering, Houston, TX, USA) were used (Fig. 1C) . Myocardial arrhythmogenic areas characterized by the presence of fractionated, long duration electrograms (≥130 ms) in sinus rhythm were identified.



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  		Fig. 1. The simultaneous recording from the multielectrode positioned on the epicardial surface of the heart. Electrograms from the normal myocardium are in (A). Fractionated and widened local signals from the periinfarct zone are in (B) (leads B3–C3). (C) The multielectrode in contact with the anterior wall of the heart.

 
In subjects without distinct left ventricular aneurysm, epicardial cryoablation encircling these areas was used without subsequent left ventriculotomy. In the remaining patients, the left ventricle was opened through the aneurysm during extracorporeal circulation. Additional endocardial mapping on normothermic heart was performed with the same probe as above. Subsequently, aneurysmectomy, subendocardial resection and cryoablation of aneurysm border zone were performed during cardioplegic heart arrest.

For cryoablation, repeated application of the purpose-built liquid nitrogen-cooled probe (KCH 5, SMT Prague, Czech Republic) were used (Fig. 2A) . The equipment consists of a control unit and a hand-held probe with the container of liquid nitrogen. The freezing tip is supplied in various shapes and diameters. After its placement at the target site, temperature of –190 °C was applied for 2–3 min with subsequent active warming.



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  		Fig. 2. (A) hand-held cryo-probe with the set of different freezing tips. (B) subendocardial resection in a patient with large anteroapical aneurysm. (C) cryoablation using the probe along the borderzone of the aneurysm.

 
Concomitant cardiac surgical procedures as indicated (aortocoronary reconstruction, aortic valve replacement, mitral valve repair) were performend after cryoablation. In the subjects who underwent aneurysmectomy and/or subendocardial resection with cryoablation, the left ventricle was closed with direct suture if the residual defect was small, or with a patch (Dacron). Moderate systemic hypothermia, aortic cross-clamping and antegrade cardioplegia with cold crystalloid (St Thomas) as well as topical cooling were used for coronary artery bypass grafting. The left internal mammary artery was preferentially used for the left anterior descending artery.

2.4. Postoperative evaluation
All of the 72 survivors of the surgery underwent a control PES, using the identical protocol as preoperatively. The study was performed within one or two weeks after the surgery. Acute success of surgical ablation was defined by the absence of spontaneous VTA in postoperative period and by noninducibility of any sustained VTA during PES.

All 23 subjects who underwent signal-averaged ECG recording before the surgery were restudied before hospital discharge using the identical equipment and setup.

2.5. Follow-up
All patients were scheduled for regular out-patient visits at an interval of 6 months. Patients with implanted ICD were followed every three months. The long-term success of the procedure was defined by the absence of spontaneous sustained VTA and/or sudden cardiac death following hospital discharge.

2.6. Statistical analysis
The data are expressed as a mean±SD. The differences between patient groups were analyzed using Fisher's exact test or {chi}2 test, when appropriate. A P value <0.05 was considered as statistically significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusions
 Appendix A. Conference...
 References
 
The median of all epicardial mapping sites with a multiarray probe was 6. The mean duration of the mapping procedure was 6.7±1.3 min. Typical fractionated local electrogram suggestive of a potential arrhythmogenic tissue is shown in Fig. 1.

Patients without an indication for ventriculotomy underwent only epicardial cryoablation. The mean number of cryolesions per patient reached 3.7±1.3. The remaining subjects underwent ventriculotomy and endocardial mapping. The median of endocardial mapping sites with a multiarray probe was 4. Subsequently, aneurysmectomy and/or subendocardial resection were performed with additional cryoablation of the transitional zones. The concomitant surgical procedures performed after surgical ablation are listed in Table 2.


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  		Table 2. Surgical intervention in 77 patients with postinfarction ventricular tachyarrhythmia

 
Five patients died perioperatively within 30 days of the surgery (6.5%). None of these patients was restudied using PES. Inducibility of any sustained VTA after surgical procedure was documented in 21 of the remaining 72 patients (29.2%). All of them underwent subsequent ICD implant. The acute success rate was analyzed in different patient subgroups (Table 3). In the subgroup of eight patients without concomitant revascularization one died in the early postoperative period and the acute success in abolishing all inducible arrhythmias was 85.7%.


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  		Table 3. The acute success of the ablation procedure in different patient population

 
The mean follow-up was 37.3±23.2 months (range 4–113). The long-term results are summarized in Table 4. None of the survivors of the perioperative period died of sudden cardiac death. In two of the postoperatively non-inducible patients, recurrence of sustained VTA was documented (at month 10 and 22 of the follow-up). In these two patients, an ICD was implanted. No significant VTA was observed during the follow-up in 14 of 23 ICD patients. Altogether, 61 patients of 72 survivors of the surgery (84.7%) remained free from spontaneous recurrences of VTA during the follow-up.


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  		Table 4. The acute and long-term operative results in 77 patients

 
All 23 patients who were examined for late potentials had the follow-up longer than 1 year. Six of them had clinical recurrences of VTA. No significant difference in filtered QRS duration was observed in these subjects, while significant shortening was documented in the remaining 17 patients (Table 5).


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  		Table 5. Signal-averaged ECG recordings

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusions
 Appendix A. Conference...
 References
 
This study summarizes an experience with a consecutive series of patients who underwent surgical ablation guided by simplified mapping in sinus rhythm and associated with myocardial revascularization, whenever indicated. To minimize the risk, we designed a strategy of arrhythmia surgery that is tailored to individual patient. Patients without discrete left ventricular aneurysm underwent only epicardial cryoablation guided by epicardial mapping in sinus rhythm. The remaining subjects were treated by aneurysmectomy and/or subendocardial resection and cryoablation.

The overall success rate of arrhythmia surgery in our series reached 70.8% with perioperative mortality of 6.5%. Although epicardial cryoablation alone tended to lower acute success rate as compared to more extensive ablation through left ventriculotomy (63.3 vs 76.2%, P<0.23), it was associated with more favorable perioperative mortality trend (3.3 vs 9.5%, P<0.30). Other authors reported acute success in abolition of all inducible VTAs within the range of 63–92% and mortality ranging from zero to 24% [5–14].

When comparing the effectiveness and safety of different approaches in prevention of the recurrences of life-threatening VTA, it is important to stress the role of coronary artery bypass surgery alone. Some authors showed that myocardial revascularization adds very few to prevention of postinfarction VTA [15,16]. On the other hand, other studies documented that coronary artery bypass surgery has an additive role in the secondary prevention of sudden arrhythmic death [17–19]. Specifically, inducibility of ventricular tachycardia or ventricular fibrillation was suppressed in about 35–45% of patients after bypass surgery [15]. Nevertheless, mortality associated with this approach without specific arrhythmia surgery may still remain relatively high (more than 22% during a mean follow-up interval of 55 months) with a total of 55% of deaths classified as sudden [20]. Therefore, coronary artery bypass surgery itself does not seem to be effective enough to protect the majority of patients with previously documented VTA from its recurrence.

The lower success rate of epicardial cryoablation in our series may reflect the location of the reentrant circuit within the myocardial wall. Although a relatively high proportion of circuits is localized in epicardial region [21,22] and thus, easily accessible from epicardial approach, other are confined solely to the subendocardium, beyond the reach of epicardial cryoablation. Furthermore, the more extensive arrhythmia surgery is likely to be more effective in abolishing VTA as compared with our less invasive approach [23]. This is also confirmed by the data from our pilot substudy of signal-averaged ECG recordings. It showed significant changes in duration of filtered QRS duration after the successful surgery and this is in concordance with the concept of more extensive substrate modification. On the other hand, such an aggressive approach carries a higher significant risk of associated mortality [9,11,12].

Success rate of surgical ablation of arrhythmogenic substrate is also influenced by the mapping accuracy. Precise identification and location of arrhythmogenic substrate for monomorphic VTA requires mapping during tachycardia and this, in turn, increases both the complexity and risk of the procedure [6,7,21]. To overcome this dilemma, various simplified techniques of identification of arrhythogenic tissue continue to be investigated. Some of them are based on anatomical landmarks [9,14] while the other rely on endocardial mapping in sinus rhythm [10]. The latter approach of sinus rhythm mapping is based on the concept that the substrate can be detected by an analysis of low amplitude, fractionated electrograms. These pathological signals appear to reflect anatomic derangement and uncoupling of myocardial fibers [24] and thus, represent potentional targets for ablation [1,2,25].

Interestingly, when analyzing different patient populations we found a trend to higher acute success rate for patients who presented with polymorphic ventricular arrhythmias or ventricular fibrillation as compared to the subjects with documented monomorphic ventricular tachycardia (81 vs 66.7%, P<0.22). The difference may be explained by the fact that polymorphic VTA are more often triggered by ischemia in contrast to monomorphic VTA associated with arrhythmogenic substrate. In the former group, myocardial revascularization appears to play important role in prevention of VTA.

During long-term follow-up, our strategy to arrhythmia surgery resulted in overall clinical control of VTA in 86% of patients. Compared to a large series of University of Pennsylvania [11] in which extensive perioperative mapping and subendocardial resection were used, mortality in our cohort was lower (6.5 vs 15%) despite very similar percentage of clinically controlled VTA in long term follow up (84.7 vs 93%). Other series [5,7,13,14] also showed better long term clinical control of VTA than was the success rate predicted by early postoperative testing. Such finding may reflect the positive long-term effect of myocardial revascularization and ventricular remodelling on electrical stability of the ventricular myocardium.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
Appendix A. Conference...
 References
 
In conclusion, surgical ablation of an arrhythmogenic substrate guided by a simplified intraoperative mapping during sinus rhythm appears to be both safe and efficacious procedure that prevents recurrences of VTA in a substantial proportion of patients.


   Acknowledgments
 
The study was supported by institutional financial support of the Ministry of Health of the Czech Republic (IKEM Research Project CEZ: L17/98: 00023001).


   Footnotes
 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A. Conference...
References
 
Dr L. Bockeria (Moscow, Russia): Why din't you go into induction of VT during surgery?

Dr Pirk: We don't make the induction of the tachycardia.

Dr Bockeria: Why?

Dr Pirk: Why? It is danger for the patient and we don't see any reason. We don't do it. That is the aim of the study. We do it in sinus rhythm and we find the focus. We don't need to induct tachycardia during surgery. It is a simplified, easier method.

Dr F. Mohr (Leipzig, Germany): May I ask in terms of your time frame, I think the experience we see is that we hardly see patients for such procedures anymore because usually they are treated by ICD treatment and are no longer referred for surgery. And you showed us your 105, if I recall it right, patients, out of a period of eight to nine years. Is there a difference in referral rate, is it an increasing number in your hospital, or is it something which is historical, as it is in our units?

Dr Pirk: No. Of course, the cardiologists are in favor to insert the defibrillator. It is easy but is a symptomatic treatment and it can have dangers.

We are trying to convince the cardiologists that this is the treatment, to find the focus, to eliminate or isolate the focus, and you cure the patient. It is not a symptomatic treatment. So I would say we have more patients.

And there is one regulation in the Czech Republic. The defibrillator is a very expensive device. So there is a committee, and every patient, before it is indicated for a defibrillator, his material must be sent to this committee, and they review all the things and they say, no, this patient can be treated by surgery or by catheter ablation, and only if this is not the case, then it is an indication for a defibrillator. So we are trying to go the other way.

Dr Mohr: You are lucky.

Dr Pirk: The patients are lucky.

Dr A. Revishvili (Moscow, Russia): I would like to ask the question about EPI study because you didn't show us what kind of tachycardia you had during surgery, how many patients in ventricular tachycardia or atrial fibrillation. During heart mapping you may have 35%, which you will want to cryoablate all the surfaces. What is the real target for your surgery?

Dr Pirk: I could not show it. We have much more data, which hopefully will be published in the paper. About 12% of the patients had a history of ventricular fibrillation. All the other patients had a history of sustained ventricular tachycardia with hypotension and with resuscitation.

Dr Revishvili: Did you induce any arrhythmia during EPI study?

Dr Pirk: Not during the surgery. In the cath lab with the programmed electrical stimulation they have been trying to do the tachycardia, and in 97 patients they were successful with evoking the tachycardia. I didn't mention this, but all the patients, of course, were on amiodarone and beta blockers and full medication before. Because of the time I could not mention everything.

Dr L. Bockeria (Moscow, Russia): I would like to say just a few words about the tendency we saw today and those who are still active in the area of arrhythmia surgery. So, what to do, maze procedure or radiofrequency ablation? This is a question which should be addressed by any surgeon to himself, because in case we have better results with a pure maze procedure, I guess we should recommend to a patient to do the type of procedure in a place where it is done. That is what we see normally now in Moscow at our hospital, which is doing a pretty big number of cases.

The second point is concerning the last presentation. Yes, the cardiological approach ‘killed’ this area of surgery, radical treatment, but it is my opinion also that in hospitals where they have an experience for this type of surgery, it should be used widely as soon as we know that this approach in experienced hands has many privileges.

When we go to radiofrequency ablation or when we use implantable cardioverter defibrillator, we are doing a palliative treatment. It should be, of course, existing in practice, but in general we should consider that the surgical approach should be used in hospitals where electrophysiology is well established, electrophysiology is still active, and where it is possible to treat patients more radically.

And the last one, what I wanted to mention is about autotransplantation of the heart. We used this approach maybe 20 years ago for the patients with long Q–T syndrome, and at least I remember two patients, a sister and a brother, eight years old. I made for both the autotransplantation of the heart, and they were doing very well. And that is understandable for me; when there is an extracardiac factor, the surgery of this type is logistic. But in cases when we do this for atrial fibrillation, it probably needs further explanation.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A. Conference...
 References
 

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