Surgical decisions in the management of sudden cardiac death and malignant ventricular arrhythmias. Subendocardial resection, the automatic internal defibrillator, or both

W. C. Hargrove, M. E. Josephson, F. E. Marchlinski, John Miller

Research output: Contribution to journalArticle

31 Citations (Scopus)

Abstract

Subendocardial resection and implantation of an automatic implantable cardioverter/defibrillator are the current preferred treatments for the management of drug-resistant malignant ventricular arrhythmias and sudden cardiac death. We reviewed retrospectively the case histories of 269 patients who had subendocardial resection and 77 patients who had defibrillator implantation to define clinical characteristics of each group and compare operative and long-term results. All patients treated by subendocardial resection had recurrent sustained ventricular tachycardia as a result of a myocardial infarction. From the standpoint of arrhythmia substrate and cardiac disease, patients receiving the defibrillator were a more heterogeneous group. Forty-eight (62%) had coronary artery disease, 28 (36%) cardiomyopathy, and one patient had a primary electrical abnormality. Among patients receiving the defibrillator, 55% had sustained ventricular tachycardia and 45% polymorphic ventricular tachycardia or ventricular fibrillation. Overall ventricular function was similar in the two groups. Operative mortality rate was better in the group having defibrillator implantation (3% versus 15%). Complications related to the defibrillator device or implantation occurred in 46 (60%) patients, with asymptomatic shocks occurring in 35 patients (45%). Since the defibrillator was not designed to prevent arrhythmias, the arrhythmia-free survival rate was much better in the group having subendocardial resection (95% versus 44% at 3 years). Fewer patients treated by subendocardial resection required antiarrhythmic medications (33% versus 66%). The actuarial survival rate was similar in the two groups (approximately 60% at 4 years), with heart failure the most common cause of death. Thus both subendocardial resection and defibrillator implantation are highly effective in preventing sudden cardiac death. The choice of procedure depends on (1) arrhythmia diagnosis, (2) cardiac disease, and (3) intangible factors.

Original languageEnglish (US)
Pages (from-to)923-928
Number of pages6
JournalJournal of Thoracic and Cardiovascular Surgery
Volume97
Issue number6
StatePublished - 1989
Externally publishedYes

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Defibrillators
Sudden Cardiac Death
Cardiac Arrhythmias
Ventricular Tachycardia
Heart Diseases
Survival Rate
Ventricular Function
Implantable Defibrillators
Ventricular Fibrillation
Cardiomyopathies
Coronary Artery Disease
Cause of Death
Shock
Heart Failure
Myocardial Infarction
Equipment and Supplies
Mortality

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

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title = "Surgical decisions in the management of sudden cardiac death and malignant ventricular arrhythmias. Subendocardial resection, the automatic internal defibrillator, or both",
abstract = "Subendocardial resection and implantation of an automatic implantable cardioverter/defibrillator are the current preferred treatments for the management of drug-resistant malignant ventricular arrhythmias and sudden cardiac death. We reviewed retrospectively the case histories of 269 patients who had subendocardial resection and 77 patients who had defibrillator implantation to define clinical characteristics of each group and compare operative and long-term results. All patients treated by subendocardial resection had recurrent sustained ventricular tachycardia as a result of a myocardial infarction. From the standpoint of arrhythmia substrate and cardiac disease, patients receiving the defibrillator were a more heterogeneous group. Forty-eight (62{\%}) had coronary artery disease, 28 (36{\%}) cardiomyopathy, and one patient had a primary electrical abnormality. Among patients receiving the defibrillator, 55{\%} had sustained ventricular tachycardia and 45{\%} polymorphic ventricular tachycardia or ventricular fibrillation. Overall ventricular function was similar in the two groups. Operative mortality rate was better in the group having defibrillator implantation (3{\%} versus 15{\%}). Complications related to the defibrillator device or implantation occurred in 46 (60{\%}) patients, with asymptomatic shocks occurring in 35 patients (45{\%}). Since the defibrillator was not designed to prevent arrhythmias, the arrhythmia-free survival rate was much better in the group having subendocardial resection (95{\%} versus 44{\%} at 3 years). Fewer patients treated by subendocardial resection required antiarrhythmic medications (33{\%} versus 66{\%}). The actuarial survival rate was similar in the two groups (approximately 60{\%} at 4 years), with heart failure the most common cause of death. Thus both subendocardial resection and defibrillator implantation are highly effective in preventing sudden cardiac death. The choice of procedure depends on (1) arrhythmia diagnosis, (2) cardiac disease, and (3) intangible factors.",
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