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. 1983 Aug;198(2):119–129. doi: 10.1097/00000658-198308000-00001

Anatomic-electrophysiologic basis for the surgical treatment of refractory ischemic ventricular tachycardia.

J L Cox
PMCID: PMC1353066  PMID: 6870366

Abstract

Recently developed surgical procedures for the treatment of refractory ischemic ventricular tachycardia have significantly improved the prognosis of patients experiencing these life-threatening arrhythmias. Ventricular tachyarrhythmias associated with ischemic heart disease most commonly originate from the ischemic border zone of myocardial infarctions, where the non-uniformity of tissue injury is most prominent. The inhomogeneity in tissue injury results in desynchronization of electrical wavefront propagation through the ischemic myocardium, thus providing the milieu necessary for the development of micro-reentrant circuits that give rise to the ventricular tachyarrhythmias. Preoperative and intraoperative electrophysiologic mapping techniques are capable of characterizing and localizing such arrhythmogenic myocardium sufficiently to direct the surgeon in his operative approach to the treatment of the arrhythmia. Surgical options include the encircling endocardial ventriculotomy, the endocardial resection procedure, endocardial cryoablation, and combinations or modifications of these three basic procedures. The use of these procedures has made the previously employed indirect surgical procedures obsolete for the treatment of refractory ischemic ventricular tachyarrhythmias.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Boineau J. P., Cox J. L. Rationale for a direct surgical approach to control ventricular arrhythmias: relation of specific intraoperative techniques to mechanism and location of arrhythmic circuit. Am J Cardiol. 1982 Feb 1;49(2):381–396. doi: 10.1016/0002-9149(82)90516-1. [DOI] [PubMed] [Google Scholar]
  2. Boineau J. P., Cox J. L. Slow ventricular activation in acute myocardial infarction. A source of re-entrant premature ventricular contractions. Circulation. 1973 Oct;48(4):702–713. doi: 10.1161/01.cir.48.4.702. [DOI] [PubMed] [Google Scholar]
  3. Braunwald E., Maroko P. R., Libby P. Reduction of infarct size following coronary occlusion. Circ Res. 1974 Sep;35 (Suppl 3):192–201. [PubMed] [Google Scholar]
  4. Cox J. L., Daniel T. M., Boineau J. P. The electrophysiologic time-course of acute myocardial ischemia and the effects of early coronary artery reperfusion. Circulation. 1973 Nov;48(5):971–983. doi: 10.1161/01.cir.48.5.971. [DOI] [PubMed] [Google Scholar]
  5. Cox J. L., Gallagher J. J., Ungerleider R. M. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. IV. Clinical indication, surgical technique, mechanism of action, and results. J Thorac Cardiovasc Surg. 1982 Jun;83(6):865–872. [PubMed] [Google Scholar]
  6. Cox J. L., McLaughlin V. W., Flowers N. C., Horan L. G. The ischemic zone surrounding acute myocardial infarction. Its morphology as detected by dehydrogenase staining. Am Heart J. 1968 Nov;76(5):650–659. doi: 10.1016/0002-8703(68)90164-6. [DOI] [PubMed] [Google Scholar]
  7. Cox J. L., Pass H. I., Wechsler A. S., Oldham H. N., Jr, Sabiston D. C., Jr Coronary collateral blood flow in acute myocardial infarction. J Thorac Cardiovasc Surg. 1975 Jan;69(1):117–125. [PubMed] [Google Scholar]
  8. El-Sherif N., Scherlag B. J., Lazzara R., Hope R. R. Re-entrant ventricular arrhythmias in the late myocardial infarction period. 1. Conduction characteristics in the infarction zone. Circulation. 1977 May;55(5):686–702. doi: 10.1161/01.cir.55.5.686. [DOI] [PubMed] [Google Scholar]
  9. Friedman P. L., Stewart J. R., Fenoglio J. J., Jr, Wit A. L. Survival of subendocardial Purkinje fibers after extensive myocardial infarction in dogs. Circ Res. 1973 Nov;33(5):597–611. doi: 10.1161/01.res.33.5.597. [DOI] [PubMed] [Google Scholar]
  10. Gallagher J. J., Anderson R. W., Kasell J., Rice J. R., Pritchett E. L., Gault H. J., Harrison L., Wallace A. G. Cryoablation of drug-resistant ventricular tachycardia in a patient with a variant of scleroderma. Circulation. 1978 Jan;57(1):190–197. doi: 10.1161/01.cir.57.1.190. [DOI] [PubMed] [Google Scholar]
  11. Gallagher J. J., Kasell J. H., Cox J. L., Smith W. M., Ideker R. E., Smith W. M. Techniques of intraoperative electrophysiologic mapping. Am J Cardiol. 1982 Jan;49(1):221–240. doi: 10.1016/0002-9149(82)90296-x. [DOI] [PubMed] [Google Scholar]
  12. Guiraudon G., Fontaine G., Frank R., Escande G., Etievent P., Cabrol C. Encircling endocardial ventriculotomy: a new surgical treatment for life-threatening ventricular tachycardias resistant to medical treatment following myocardial infarction. Ann Thorac Surg. 1978 Nov;26(5):438–444. doi: 10.1016/s0003-4975(10)62923-2. [DOI] [PubMed] [Google Scholar]
  13. Hearse J. D., Opie L. H., Katzeff I. E., Lubbe W. F., Van der Werff T. J., Peisach M., Boulle G. Characterization of the "border zone" in acute regional ischemia in the dog. Am J Cardiol. 1977 Nov;40(5):716–726. doi: 10.1016/0002-9149(77)90187-4. [DOI] [PubMed] [Google Scholar]
  14. Hirzel H. O., Sonnenblick E. H., Kirk E. S. Absence of a lateral border zone of intermediate creatine phosphokinase depletion surrounding a central infarct 24 hours after acute coronary occlusion in the dog. Circ Res. 1977 Nov;41(5):673–683. doi: 10.1161/01.res.41.5.673. [DOI] [PubMed] [Google Scholar]
  15. Ideker R. E., Smith W. M., Wallace A. G., Kasell J., Harrison L. A., Klein G. J., Kinicki R. E., Gallagher J. J. A computerized method for the rapid display of ventricular activation during the intraoperative study of arrhythmias. Circulation. 1979 Mar;59(3):449–458. doi: 10.1161/01.cir.59.3.449. [DOI] [PubMed] [Google Scholar]
  16. Josephson M. E., Harken A. H., Horowitz L. N. Endocardial excision: a new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation. 1979 Dec;60(7):1430–1439. doi: 10.1161/01.cir.60.7.1430. [DOI] [PubMed] [Google Scholar]
  17. Josephson M. E., Horowitz L. N., Farshidi A., Spear J. F., Kastor J. A., Moore E. N. Recurrent sustained ventricular tachycardia. 2. Endocardial mapping. Circulation. 1978 Mar;57(3):440–447. doi: 10.1161/01.cir.57.3.440. [DOI] [PubMed] [Google Scholar]
  18. Josephson M. E., Horowitz L. N., Farshidi A., Spielman S. R., Michelson E. L., Greenspan A. M. Recurrent sustained ventricular tachycardia. 4. Pleomorphism. Circulation. 1979 Mar;59(3):459–468. doi: 10.1161/01.cir.59.3.459. [DOI] [PubMed] [Google Scholar]
  19. LUSHNIKOV E. F. HISTOCHEMICAL STUDY OF EXPERIMENTALLY PRODUCED MYOCARDIAL INFARCTION. Fed Proc Transl Suppl. 1963 Sep-Oct;22:906–910. [PubMed] [Google Scholar]
  20. Mikat E. M., Hackel D. B., Harrison L., Gallagher J. J., Wallace A. G. Reaction of the myocardium and coronary arteries to cryosurgery. Lab Invest. 1977 Dec;37(6):632–641. [PubMed] [Google Scholar]
  21. Sealy W. C., Gallagher J. J., Kasell J. His bundle interruption for control of inappropriate ventricular responses to atrial arrhythmias. Ann Thorac Surg. 1981 Nov;32(5):429–438. doi: 10.1016/s0003-4975(10)61774-2. [DOI] [PubMed] [Google Scholar]
  22. Spurrell R. A., Yates A. K., Thorburn C. W., Sowton G. E., Deuchar D. C. Surgical treatment of ventricular tachycardia after epicardial mapping studies. Br Heart J. 1975 Feb;37(2):115–126. doi: 10.1136/hrt.37.2.115. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Ungerleider R. M., Holman W. L., Calcagno D., Williams J. M., Lofland G. K., Smith P. K., Stanley T. E., 3rd, Quick G., Cox J. L. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. III. Effects on regional left ventricular function. J Thorac Cardiovasc Surg. 1982 Jun;83(6):857–864. [PubMed] [Google Scholar]
  24. Ungerleider R. M., Holman W. L., Stanley T. E., 3rd, Lofland G. K., Williams J. M., Ideker R. E., Smith P. K., Quick G., Cox J. L. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. I. Electrophysiological effects. J Thorac Cardiovasc Surg. 1982 Jun;83(6):840–849. [PubMed] [Google Scholar]
  25. Ungerleider R. M., Holman W. L., Stanley T. E., 3rd, Lofland G. K., Williams J. M., Smith P. K., Quick G., Cox J. L. Encircling endocardial ventriculotomy for refractory ischemic ventricular tachycardia. II. Effects on regional myocardial blood flow. J Thorac Cardiovasc Surg. 1982 Jun;83(6):850–856. [PubMed] [Google Scholar]
  26. Williams J. M., Ungerleider R. M., Lofland G. K., Cox J. L. Left atrial isolation: new technique for the treatment of supraventricular arrhythmias. J Thorac Cardiovasc Surg. 1980 Sep;80(3):373–380. [PubMed] [Google Scholar]
  27. Wit A. L., Cranefield P. F. Reentrant excitation as a cause of cardiac arrhythmias. Am J Physiol. 1978 Jul;235(1):H1–17. doi: 10.1152/ajpheart.1978.235.1.H1. [DOI] [PubMed] [Google Scholar]

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