Surgery for postinfarction ventricular tachycardia in the pre-implantable cardioverter defibrillator era: early and long term outcomes in 100 consecutive patients

Abstract

Objective: To report outcome following surgery for postinfarction ventricular tachycardia undertaken in patients before the use of implantable defibrillators.

Design: A retrospective review, with uniform patient selection criteria and surgical and mapping strategy throughout. Complete follow up. Long term death notification by OPCS (Office of Population Censuses and Statistics) registration.

Setting: Tertiary referral centre for arrhythmia management.

Patients: 100 consecutive postinfarction patients who underwent map guided endocardial resection at this hospital in the period 1981-91 for drug refractory ventricular tachyarrhythmias.

Results: Emergency surgery was required for intractable arrhythmias in 28 patients, and 32 had surgery within eight weeks of infarction ("early"). Surgery comprised endocardial resections in all, aneurysmectomy in 57, cryoablations in 26, and antiarrhythmic ventriculotomies in 11. Twenty five patients died < 30 days after surgery, 21 of cardiac failure. This high mortality reflects the type of patients included in the series. Only 12 received antiarrhythmic drugs after surgery. Perioperative mortality was related to preoperative left ventricular function and the context of surgery. Mortality rates for elective surgery more than eight weeks after infarction, early surgery, emergency surgery, and early emergency surgery were 18%, 31%, 46%, and 50%, respectively. Actuarial survival rates at one, three, five, and 10 years after surgery were 66%, 62%, 57%, and 35%.

Conclusions: Surgery offers arrhythmia abolition at a risk proportional to the patient's preoperative risk of death from ventricular arrhythmias. The long term follow up results suggest a continuing role for surgery in selected patients even in the era of catheter ablation and implantable defibrillators.

Figure 1

Number of patients operated on each year in the series of 100 patients. Series ended with change in surgical selection criteria made possible by advent of implantable defibrillators.

Figure 2

Actuarial survival for the study group and, for comparison, actuarial curves for cohorts of patients from published reports undergoing coronary revascularisation alone,²⁹ and aneurysmectomy for angina or for heart failure.³⁰ CABG, coronary artery bypass graft; LVF, left ventricular failure.