Surgical ventricular reconstruction with endocardectomy along radiofrequency ablation-induced markings.

OBJECTIVE: The objective of this study was to evaluate the efficacy of a novel approach for endocardectomy during coronary artery bypass graft with surgical ventricular restoration in patients with postinfarction left ventricular aneurysm. METHODS: One hundred sixty-eight patients underwent coronary artery bypass graft with surgical ventricular restoration from 2005 to 2011. Endocardectomy was performed as an integral part of surgical ventricular restoration for the prevention of ventricular tachycardia. The experimental group (surgical ventricular restoration-endocardectomy group; n = 74) underwent preoperative electrophysiologic study with electroanatomic left ventricular mapping. Radiofrequency ablation-induced markings were placed and were used later as guides for performing endocardectomy during coronary artery bypass graft with surgical ventricular restoration. The control group (surgical ventricular restoration group; n = 94) underwent surgical ventricular restoration without endocardectomy. RESULTS: The 1-year mortality rates in the surgical ventricular restoration-endocardectomy and surgical ventricular restoration (control) groups were 5% and 13%, respectively. During the postoperative period, 3% of patients in the surgical ventricular restoration-endocardectomy group and 38% of patients in the surgical ventricular restoration group experienced ventricular tachycardia events (P < .05). Automatic implantable cardioverter-defibrillators were implanted in 11 patients in the surgical ventricular restoration group and in 1 patient of the surgical ventricular restoration-endocardectomy group for secondary prevention of sudden cardiac death. CONCLUSIONS: When performed as an integral part of surgical ventricular restoration, endocardectomy was crucial in preventing postoperative ventricular tachycardia. Use of radiofrequency ablation-induced markings allowed clear visualization of the reentry zones for efficient endocardectomy during coronary artery bypass graft with surgical ventricular restoration, resulting in better patient outcomes.

Unusual complications of percutaneous epicardial access and epicardial mapping and ablation of cardiac arrhythmias.

BACKGROUND: Percutaneous epicardial access and mapping/ablation of cardiac arrhythmias are being increasingly performed. Although complications such as pericardial effusion are relatively common, other unusual complications may occur due to the complex anatomic architecture of the heart and surrounding tissues. In this report, we report a series of rare and unusual complications related to percutaneous epicardial procedures. METHODS AND RESULTS: Between 2006 and 2011, 334 patients underwent attempts at percutaneous, subxiphoid access for epicardial mapping/ablation at 5 experienced centers. Seven selected complications are highlighted in this case series. Patient 1 had a 1-cm right ventricular pseudoaneurysm after several unsuccessful attempts at epicardial access. This was successfully managed conservatively. Patient 2 had intra-abdominal bleeding related to puncture of the left lobe of the liver during access that required surgical repair. Patient 3 had a subcapsular hepatic hematoma that was probably related to percutaneous access and was successfully managed conservatively. Patient 4 had severe pericardial bleeding followed by ventricular fibrillation, immediately after obtaining percutaneous epicardial access. A lacerated middle cardiac vein was repaired surgically. However, the patient ultimately died of complications. Patient 5 had a history of cardiothoracic surgery and developed a right ventricle-abdominal fistula after multiple attempts at percutaneous access. This was surgically repaired without major sequelae. Patient 6 had cardiac tamponade caused by a lacerated coronary sinus branch during epicardial catheter ablation and required surgical repair. Patient 7 had severe left coronary vasospasm and ventricular fibrillation during catheter manipulation in the pericardium. This complication was successfully managed with intracoronary nitrates. CONCLUSIONS: Though generally safe, percutaneous epicardial access and mapping/ablation can result in uncommon complications. Awareness of these rare complications may facilitate early detection and successful management.

Paced skeletal muscle for dynamic cardiomyoplasty.

Four patients, each with a history of myocardial infarction and diffuse coronary artery disease, underwent application of left latissimus dorsi (LD) muscle with intact neurovascular bundle to the anterolateral wall of the left ventricle. The muscle was conditioned over a six-week period subsequent to operation in 3 patients and was conditioned preoperatively with a burst stimulus in the fourth. Biopsy specimens confirm the experimental data that human skeletal muscle can be electrically conditioned over a six- to ten-week period to contain mainly fatigue-resistant type I fibers. All patients survived the procedure, and 3 showed improvement secondary to aneurysmectomy. In Patient 1, a modified resection was performed, and at 28 months after operation, at the 75-W level of exercise, the ejection fraction was 54% paced versus 45% nonpaced. In Patient 2, at 12 months, the ejection fraction at rest was 44% paced versus 30% nonpaced. Doppler echo studies confirmed the presence of the flap and its function in the paced and nonpaced mode. The third patient died of a sudden ventricular arrhythmia 2 months following operation. An infected, nonfunctioning, degenerated flap was found at autopsy. Patient 4 did not have an aneurysm. She received a bypass graft to the right coronary artery and underwent cardiomyopexy in an attempt to relieve medically refractory incapacitating chronic congestive heart failure. Ten months postoperatively, ejection fraction at rest was 33% paced versus 25% nonpaced. Constrictive myopathy has not been encountered in any of these patients.