title: Surgical ablation of refractory ventricular tachycardia in patients with nonischemic cardiomyopathy.
abstract: BACKGROUND
  The surgical approach for the treatment of ventricular tachycardia (VT) has been largely replaced by percutaneous, catheter-based techniques. However, some VT circuits, particularly in patients with nonischemic cardiomyopathy, remain inaccessible to percutaneous ablation. Surgical therapy of these VTs is an alternative approach; however, its methodology has not been well defined. The purpose of this study was to evaluate the efficacy of preoperative electroanatomic and electrophysiological characterization of the VT substrate and circuit to guide surgical ablation.
  
  
  RESULTS
  Eight patients with recurrent sustained VT refractory to antiarrhythmic drugs underwent endocardial and/or epicardial ablation procedures. Electroanatomic mapping was performed, and the VT substrate and circuit(s) were defined using voltage, activation, entrainment, and pace mapping. All 8 patients underwent detailed endocardial mapping; 6 patients also underwent epicardial mapping. Radiofrequency ablation was performed with the use of an open-irrigation catheter. After the unsuccessful percutaneous approach, surgical cryoablation was applied to the sites previously identified and targeted during the percutaneous procedure. There were no significant perioperative complications. During a mean follow-up period of 23 ± 6 months (range, 15 to 34 months), 6 patients had significant reduction in VT burden as evident by a reduced number of implantable cardioverter-defibrillator shocks after ablation (6.6 to 0.6 shocks per patient; P = 0.026). Two patients died, one of progressive heart failure and one of sepsis.
  
  
  CONCLUSIONS
  VT circuits inaccessible to percutaneous ablation techniques are rare but can be encountered in patients with nonischemic cardiomyopathy. These VTs can be successfully targeted by surgical cryoablation guided by preoperative electroanatomic and electrophysiological mapping.
authors.affiliation: Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Elad
authors.initials: E
authors.lastname: Anter
authors.forename: Mathew D
authors.initials: MD
authors.lastname: Hutchinson
authors.forename: Rajat
authors.initials: R
authors.lastname: Deo
authors.forename: Haris M
authors.initials: HM
authors.lastname: Haqqani
authors.forename: David J
authors.initials: DJ
authors.lastname: Callans
authors.forename: Edward P
authors.initials: EP
authors.lastname: Gerstenfeld
authors.forename: Fermin C
authors.initials: FC
authors.lastname: Garcia
authors.forename: Rupa
authors.initials: R
authors.lastname: Bala
authors.forename: David
authors.initials: D
authors.lastname: Lin
authors.forename: Michael P
authors.initials: MP
authors.lastname: Riley
authors.forename: Harold I
authors.initials: HI
authors.lastname: Litt
authors.forename: Joseph Y
authors.initials: JY
authors.lastname: Woo
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.forename: Erica S
authors.initials: ES
authors.lastname: Zado
authors.forename: Francis E
authors.initials: FE
authors.lastname: Marchlinski
authors.forename: Sanjay
authors.initials: S
authors.lastname: Dixit
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D009202:Cardiomyopathies / Q000453:epidemiology*; D013504:Cardiovascular Surgical Procedures / Q000379:methods*; D017115:Catheter Ablation / Q000379:methods*; D015897:Comorbidity; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D017180:Tachycardia, Ventricular / Q000188:drug therapy / Q000453:epidemiology* / Q000601:surgery*; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents