Ventricular Arrhythmias after LV Remodelling: Surgical Ventricular Restoration or ICD?

Abstract

Favorable electrical success rate and low mortality always included volume reduction to interrupt functional re-entry circuits, but also added endocardiectomy, cryoablation, CABG and mitral repair when needed. Overall SVR findings show volume and shape alteration limits ventricular arrhythmias that impair prognosis, and suggests ICD devices are not needed.

Impact of Surgical Ventricular Restoration on Cardiac Function, Ischaemic Mitral Regurgitation and Long-term Survival

“…This is to allow myocardial coupling, reduction of LV wall tension and improvement in ejection fraction. This correlates with reduction in the grade of functional MR and clinically improved NYHA class for all patients [23]. If mitral repair is not undertaken there might be an irreversible decline in LV viability, increase in chamber dimensions, wall stress and a poor surgical outcome [24].…”

Surgical Ventricular Restoration to Reverse Left Ventricular Remodeling

“…These events include LV dilatation, which, in turns, increases wall stress and stretch (stretch is arrhythmogenic per sè), and to the presence of electrically unexcitable scars. Our group has previously demonstrated that patients with ventricular arrhythmias (spontaneous or inducible) have end-diastolic and endsystolic volumes significantly larger than those seen in noninducible patients [65,66]. SVR has the potential to reduce ventricular arrhythmias by excluding the scar, reducing volumes and thus intraventricular stress and stretch.…”

“…Ventricular arrhythmias are further reduced by relieving ischemia through complete revascularization and improving mechanical resynchronization. So far, different groups have reported a marked reduction of inducible arrhythmias and a very low incidence of sudden death after SVR [20,[65][66][67]. This may limit the need for ICD implantation in patients who undergo SVR.…”

Sudden Cardiac Death after Heart Failure; Symptomatic versus Disease Treatment? An Editorial Comment

“…Conversely, the Di Donato paper in this Issue [7] shows that amniodorone was very successful in the 26 of 382 patients undergoing LV restoration that showed postoperative arrhythmia by paired ventricular stimulation. We suspect the underlying central theme for this good effect is reduction of LV volume by rebuilding.…”

“…Limitations of prior surgical efforts to treat this terminal electrical event are also emphasized in Di Donato's paper [7] by showing how singular interventions like aneurysmectomy alone [8], mapping or non mapping-guided endocardial resection with or without LV aneurysmectomy [9,10], catheter ablation [11,12], revascularization alone [13] were unsuccessful. However, the failure of this direct approach to eradicate arrhythmias alone served as the stimulus to Dor's adding LV restoration to supplement these established therapies, as rebuilding a more normal left ventricular size and shape provided a more global approach to treating sudden death [14,15].…”