Surgery for ventricular tachycardia of left ventricular origin: risk factors for success and long-term outcome.
OBJECTIVE
To review 26 consecutive patients with sustained monomorphic ventricular tachycardia (VT) of left ventricular origin, who underwent direct VT surgery.


METHODS
Economic factors precluded the use of an implantable cardioverter defibrillator (ICD) in the majority of these patients, and the indication for surgery in 81% of patients was for failed medical drug therapy and 27% of patients had frequent or incessant life-threatening VT. The principles of direct VT surgery included intraoperative mapping, extended endocardial resection, cryoablation, left ventricular aneurysm repair by left ventricular remodelling and endoaneurysmorrhaphy, as well as coronary artery bypass grafting.


RESULTS
Two patients with non-ischaemic VT were significantly younger (37.7 +/- 19.4 years, P = 0.03), had lower preoperative New York Heart Association class (P = 0.03), and had better left ventricular ejection fractions of 59.5 +/- 2.1% (P = 0.001) than the 24 ischaemic patients. No operative mortality or recurrence of VT occurred in this group. Ischaemic VT patients had an operative mortality of 8.3%; risk factors were concomitant valve surgery (P = 0.02), and perioperative intra-aortic balloon pump (P = 0.02). Surgery improved the left ventricular ejection fraction from 28.4 +/- 9.8% to 43.2 +/- 8.2% (P = 0.0001). Freedom from recurrence or inducibility of VT in operative survivors was 78.8 +/- 9.6% at 10 years; risk factors were arrhythmic focus remote to the left ventricular aneurysm (P = 0.015), and simple cryoablation or endocardial resection alone and not in combination (P = 0.003). Survival was 54.1 +/- 11.6% and 43.3 +/- 13.4% at 5 and 10 years, respectively, and there were no arrhythmic or sudden cardiac deaths. Patients with immediately life-threatening VT unsuitable for ICD implantation requiring urgent or emergent VT surgery had a 10-year survival of 22.2 +/- 13.9% compared to the more elective surgical group with a rate of 73.3 +/- 13.9% (P = 0.08).


CONCLUSIONS
Direct VT surgery should remain an objective for symptomatic drug refractory VT of left ventricular origin.
von Oppell
Ulrich Otto
UO
Department of Cardiothoracic Surgery, Cardiac Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK. uvonopp@uhw-tr.wales.nhs.uk
Milne
Dave
D
Okreglicki
Andrzej
A
Scott Millar
Robert Norman
RN
D000328:Adult; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D003452:Cryosurgery; D018572:Disease-Free Survival; D022062:Electrophysiologic Techniques, Cardiac; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate; D017180:Tachycardia, Ventricular / Q000188:drug therapy / Q000209:etiology / Q000601:surgery*; D017211:Treatment Failure; D016896:Treatment Outcome; D016277:Ventricular Function, Left
D000889:Anti-Arrhythmia Agents