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J Thorac Cardiovasc Surg 2005;130:1250-1256
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Residual high incidence of ventricular arrhythmias after left ventricular reconstructive surgery

^a Department of Cardiovascular Medicine, Section of Heart Failure and Cardiac Transplant Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio.
^b Department of Cardiovascular Medicine, Section of Cardiac Electrophysiology and Pacing, The Cleveland Clinic Foundation, Cleveland, Ohio.
^c Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio.
^d Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, Cleveland, Ohio.

Received for publication February 17, 2005; revisions received June 27, 2005; accepted for publication June 30, 2005.

^_* Address for reprints: Mina K. Chung, MD, FACC, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Desk F15, 9500 Euclid Ave, Cleveland, OH 44195 (Email: Chungm{at}ccf.org).

OBJECTIVE: Left ventricular reconstruction is performed in patients with ischemic cardiomyopathy and akinetic or dyskinetic left ventricular regions. These patients may remain at risk for malignant ventricular arrhythmias and hence may benefit from prophylactic implantable cardioverter-defibrillators. Specific guidelines for electrophysiologic testing and implantable cardioverter-defibrillator implantation in patients undergoing left ventricular reconstruction are lacking. We aimed to assess the residual risk and timing of ventricular arrhythmias after left ventricular reconstruction to determine whether electrophysiologic risk stratification or implantable cardioverter-defibrillator implantation can be safely deferred.

METHODS: Data were prospectively gathered on 217 consecutive patients with left ventricular ejection fractions less than 40% undergoing left ventricular reconstruction at our institution from 1997 to 2002. Patients were divided into 3 groups: group 1, implantable cardioverter-defibrillator present before surgery; group 2, implantable cardioverter-defibrillator implanted early after surgery; and group 3, no implantable cardioverter-defibrillator implanted. End points were all-cause mortality (censored for cardiac transplantation) and appropriate implantable cardioverter-defibrillator therapies.

RESULTS: Of 217 patients (mean age, 61 ± 10 years [mean ± SD]), survival after a median follow-up of 381 days was 90%. Electrophysiologic studies successfully identified patients at low risk. Appropriate implantable cardioverter-defibrillator therapies occurred in 20% of group 1 and 12% of group 2. The median time to the first implantable cardioverter-defibrillator therapy from the time of left ventricular reconstruction was 43 days, and most first therapies (67%) occurred within the first 63 days.

CONCLUSIONS: The early event rates (occurring in the first 90 days after left ventricular reconstruction) support the use of predischarge electrophysiologic studies, implantation of implantable cardioverter-defibrillators before discharge from the hospital, or both.

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