Prophylactic automatic implantable cardioverter-defibrillator patches in patients at high risk for postoperative ventricular tachyarrhythmias

Abstract

The strategy of placing prophylactic patches for the automatic implantable cardioverter-defibrillator (AICD) without the AICD was employed in 34 patients with coronary artery disease at risk for postoperative ventricular tachycardia undergoing coronary bypass graft surgery (12 patients) or subendocardial resection (22 patients). Patients were selected on the basis of the presence of preoperative sustained ventricular tachycardia (25 patients) or ventricular fibrillation (9 patients) and absence of control of the arrhythmia with 3.6 ± 1.3 antiarrhythmic drugs by programmed stimulation. Patients having subendocardial resection were also selected on the basis of multiple configurations of ventricular tachycardia, inability to map the tachycardia or posterior wall aneurysm.The surgical mortality rate was 12%, with two deaths after coronary bypass graft surgery and two deaths after subendocardial resection. The AICD patches were removed in 1 of the 34 patients a few hours after surgery because of left atrial laceration and bleeding. Among 10 patients surviving coronary bypass surgery alone, ventricular arrhythmia was not inducible in 6 and in 4 it remained inducible postoperatively. One of the four patients with inducible arrhythmia had the AICD implanted with use of local anesthesia; the other three were treated with drugs. Among 20 patients surviving subendocardial resection, ventricular arrhythmia was noninducible in 15 and remained inducible in 5. Three of these five patients had an AICD implanted; the other two were treated with drugs.At 12 ± 7 month follow-up, there were no late deaths. One patient with an inducible arrhythmia after coronary bypass surgery who was treated with drugs had a recurrence 4 months after discharge and received the AICD. One patient without an inducible arrhythmia after subendocardial resection had an AICD implanted for arrhythmia recurrence 1 year later. Thus, 6 (20%) of the 30 patients surviving surgery required an implanted AICD postoperatively. No late complications from the patches have occurred.In conclusion, selective placement of prophylactic AICD patches in patients at risk for postoperative ventricular tachycardia is safe and obviates the need for subsequent thoracotomy in the 20% of patients who eventually need the AICD.