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J Thorac Cardiovasc Surg 1994;107:648-0649
© 1994 Mosby, Inc.

Letters to the Editor

The endocardial versus the epicardial approach: Still a controversy?

Jorge Wernly, MD

University of New Mexico

Department of Thoracic and Cardiovascular Surgery

Albuquerque, NM 87131

To the Editor:

Recent advances in the treatment of Wolff-Parkinson-White syndrome with radio frequency catheter ablation have dramatically changed the practice of arrhythmia surgery. Radiofrequency catheter ablation is now the treatment of choice and fewer patients undergo operations, usually after failure of the ablation procedure. During a recent experience with division of a left free-wall pathway with the endocardial technique after failure of the catheter ablation technique, we were surprised by the amount of coagulation necrosis of the posterior ventricular wall associated with friable tissues and obliteration of the surgical planes. These findings are probably related to our early intervention 1 week after a radiofrequency ablation attempt, and we would expect a firmer and denser scar later on during the healing process. Surgical dissection was particularly difficult. Similar findings have been reported by others. ^{1, 2}

This case stimulates a few points of discussion. First, we should be concerned about timing of surgical intervention after catheter ablation: Should we operate early on in the presence of friable tissues yet separable in planes, or wait and later perform the dissection into a dense and well-formed scar? The experience is so limited that no firm recommendation is available; we suspect that today surgical division after catheter ablation is considered an elective procedure and scheduled according to the patient's convenience, except for those pathways with a short refractory period and the risk of sudden death, as in our case.

Second, we should ask ourselves which technique will offer the best results in this subset of patients. Recent reports ^{2, 3} have suggested selective use of the epicardial and endocardial techniques, depending on the pathway location. In the future, however, with the decreasing number of surgical cases, it will be difficult to maintain adequate skill in both techniques and most likely only one will prevail.

One way to classify the procedures for treatment of Wolff-Parkinson-White syndrome is to separate them as physiologic (radiofrequency catheter ablation, epicardial technique) and anatomic (endocardial technique). Physiologic treatments are performed on a beating heart and the extension of the radiofrequency lesion or the width of the dissection with the epicardial technique is determined by the location of the pathway at mapping. The anatomic treatment is done with cardioplegic arrest and is complete only after the entire anatomic space containing the accessory pathway has been dissected. As a result, the efficacy of the anatomic procedures is almost 100% (99% for the endocardial technique), versus 90% to 96% for the physiologic procedures (90% for radiofrequency catheter ablation and 96% for the epicardial technique). ⁴ The reason the physiologic procedures have lesser success is unclear, but it is conceivable that the localized injury produced by radiofrequency current and the less extensive dissection associated with the epicardial technique may incompletely or only partially divide the pathway.

In the years to come, patients undergoing surgical division will come to us after one or more long sessions in the electrophysiology laboratory, with high expectation for a definitive cure. Under these circumstances, the technique with the best success rate should probably be recommended and probably should be an anatomic procedure because the physiologic approach has already failed. In addition, there is no question that a difficult dissection of the atrioventricular groove is best performed in a dry, quiet operative field, rather than a bloody environment with a beating heart.

Because our experience with surgical treatment of Wolff-Parkinson-White syndrome after catheter ablation failure is anecdotal, these are only personal reflections after a recent case. After all, it may be that a controversy on a surgical technique will be solved by cardiologists!

References

1. Bolling SF, Morady F, Calkins H, et al. Current treatment for Wolff-Parkinson-White syndrome: results and surgical implications. Ann Thorac Surg 1991;52:461-8.[Abstract]
   
2. Edwards FH, Weston L. Surgical management of posteroseptal accessory atrioventricular pathways. Ann Thorac Surg 1992;53:321-5.[Abstract]
   
3. Geha AS, Biblo LA, Carlson MD, Waldo AL. Selective surgical approach for atrioventricular reentrant tachycardia. Ann Thorac Surg 1992;53:200-6.[Abstract]
   
4. Ferguson TB Jr. Surgical treatment of Wolff-Parkinson-White syndrome. Ann Thorac Surg 1990;50:866-7.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fabrizio Follis Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Follis, F. Search for Related Content PubMed PubMed Citation Articles by Follis, F.