J Thorac Cardiovasc Surg 2006;131:1210-1211
© 2006 The American Association for Thoracic Surgery
Implantable cardioverter-defibrillator after left ventricular reconstruction?
Ulrik Sartipy, MD,
Anders Albåge, MD, PhD,
Dan Lindblom, MD, PhD
Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, S-171 76 Stockholm, Sweden
 |
Introduction
|
|---|
To the Editor:
We read with great interest the article by O'Neill and coworkers,
1
which addresses an important question: Is implantable cardioverter-defibrillator (ICD) implantation indicated after left ventricular reconstruction (LVR)?
The authors present their large experience of LVR as a nontransplant surgical strategy for patients with heart failure, with a focus on postoperative malignant arrhythmias. Primary end points were all-cause mortality and appropriate ICD therapies, and median follow-up was 381 days. In addition to the LVR, a small proportion of patients (13%) received a specific antiarrhythmic surgical procedure consisting of cryoablation, about half (46%) underwent a mitral valve procedure, and most patients (88%) were revascularized. The main findings were that patients remain at high risk of ventricular arrhythmias after LVR and that the arrhythmias occur early postoperatively, in two thirds of the cases within 90 days. The authors recommend early ICD implantation or electrophysiology (EP)–guided ICD therapy before hospital discharge after LVR.
We have 2 questions regarding the study by O'Neill and coworkers
1
: (1) How many patients had clinical arrhythmias before surgical intervention? (2) Were EP studies conducted before surgical intervention in any of the patients?
The answers to these questions are important to assess the effect of the procedure per se on the incidence of postoperative arrhythmias. There is some theoretic or indirect evidence that LVR promotes electrical stability in the heart by different mechanisms.
2
At our institution, most patients eligible for LVR undergo a preoperative EP study. In patients with spontaneous or inducible ventricular tachycardia (VT), we perform endocardial resection and cryoablation. In patients with preoperative clinical VT, we perform an EP study before hospital discharge, and in patients with inducible-only VT, we perform an EP study 3 to 6 months after the operation. In case of postoperative clinical or inducible VT, we recommend ICD implantation. We have recently reported our experience in a series of 53 consecutive patients undergoing LVR and surgical intervention for VT.
3
The success rate in terms of VT control was 90%. This finding is comparable to the results previously reported by Di Donato and colleagues
4
and Mickleborough and associates.
5
|
Treat the cause, not the symptoms
|
|---|
ICD firing is associated with a certain amount of discomfort for the patient. ICDs indisputably save lives, but the price can be high both in terms of money and patient well-being. Therefore the aim must be to eliminate the need for ICD. By adding specific antiarrhythmic surgical procedures, such as endocardectomy and cryoablation, in patients undergoing LVR, we have a potentially curative treatment option at our disposal. In our view an EP study is necessary after LVR when surgical intervention for VT has been included to identify surgical failures in which ICD therapy is warranted.
In our opinion patients scheduled for LVR should be assessed for ventricular arrhythmias, and if present, specific arrhythmia surgery should be performed concomitantly, and the postoperative result should be verified by means of EP studies. With this protocol, implantation of an ICD will not be needed in most patients after LVR including surgical intervention for VT.
|
References
|
|---|
- O'Neill JO, Starling RC, Khaykin Y, et al. Residual high incidence of ventricular arrhythmias after left ventricular reconstructive surgery. J Thorac Cardiovasc Surg 2005;130:1250-1256.[Abstract/Free Full Text]
- Koilpillai C, Quinones MA, Greenberg B, et al. Relation of ventricular size and function to heart failure status and ventricular dysrhythmia in patients with severe left ventricular dysfunction. Am J Cardiol 1996;77:606-611.[Medline]
- Sartipy U, Albåge A, Strååt E, Insulander P, Lindblom D. Surgery for ventricular tachycardia in patients undergoing left ventricular reconstruction by the Dor procedure. Ann Thorac Surg 2006;81:65-71.[Abstract/Free Full Text]
- Di Donato M, Sabatier M, Dor V. Surgical ventricular restoration in patients with postinfarction coronary artery disease. effectiveness on spontaneous and inducible ventricular tachycardia. Semin Thorac Cardiovasc Surg 2001;13:480-485.[Medline]
- Mickleborough LL, Merchant N, Ivanov J, Rao V, Carson S. Left ventricular reconstruction. early and late results. J Thorac Cardiovasc Surg 2004;128:27-37.[Abstract/Free Full Text]
Related Article
-
Reply to the Editor
- Mina K. Chung and James O. O'Neill
J. Thorac. Cardiovasc. Surg. 2006 131: 1211.
[Extract]
[Full Text]
[PDF]
Top
Introduction
Treat the cause, not...