Surgical treatment of life-threatening ventricular arrhythmias: The role of intraoperative mapping and consideration of the presently available surgical techniques

Abstract

T IS well known that ventricular arrhythmias may be serious and even life-threatening. Furthermore, it is also known that these arrhythmias may not be adequately controlled with available medical therapy. It is a logical consequence that if the region of the myocardium responsible for generating such arrhythmias could be identified and was amenable to effective surgical treatment, such treatment would be not only desirable, but also would be a significant advance in antiarrhythmic therapy. The first surgical approach to treatment of ventricular arrhythmia was that reported by Couch,’ who performed a surgical resection of a left ventricular aneurysm as treatment of a lifethreatening arrhythmia in one patient. With the subsequent advances in the various techniques of cardiac catheterization, cardiac electrophysiology, and open heart surgery, it is a natural outgrowth that surgical approaches to treatment of these serious and life-threatening arrhythmias should be considered. The first systematic approach to intraoperative electrophysiologic investigation of ventricular arrhythmias with subsequent therapeutic surgical intervention was reported in 1974 by Fontaine et al.’ They studied three patients with right ventricular tachycardia utilizing epicardial mapping at the time of surgery, followed by selective right ventriculotomy as the surgical therapy. Since that time, active investigation in this field has continued to the point where it is probably reasonable to suggest that we may be at the threshold of yet another era in cardiac surgery, namely, the surgical treatment of lifethreatening ventricular arrhythmias. This article reviews the utility and application of intraoperative electrophysiologic mapping in patients with serious or life-threatening ventricular arrhythmias. In addition, it reviews the present state of surgical treatment of these ventricular arrhythmias.