Selle J G, Svenson R H, Gallagher J J, Littmann L, Sealy W C, Robicsek F
Department of Medicine, Carolinas Medical Center, Charlotte, North Carolina.
Pacing Clin Electrophysiol. 1992 Sep;15(9):1357-61.
Directed surgery for the definitive treatment of drug resistant ventricular tachycardia (VT) due to coronary artery disease carries a significant operative mortality. Surgical failure to cure VT remains a problem, especially in patients without anterior left ventricular myocardial infarcts and aneurysms. A method has been developed in which Nd:YAG laser is used to photocoagulate myocardium responsible for the initiation of VT using a "sequential" approach intended to improve operative results and gain insight into the variable substrates causing VT.
Under normothermic cardiopulmonary bypass, VT is induced and then extensive endocardial and epicardial mapping performed to localize and characterize that form of VT. Nd:YAG is applied to the areas of myocardium from which that form of VT originates until it disappears and is no longer inducible. Next attempts are made to induce other forms of VT and when successful, mapping and lasing repeated until finally VT is no longer inducible.
Fifty-one patients were operated on and have been followed for at least 1 year. Operative mortality in 12 patients with preoperative ejection fractions less than 20% was 41%; in 39 patients with ejection fractions greater than 20% operative mortality was 8%. Eighty-eight percent of the 43 operative survivors are free of recurrent sustained VT at 1 year. There have been no arrhythmic mortalities. In a group of 30 patients evaluated for epicardial VT, 9 of 14 patients with inferior infarcts without left ventricular aneurysms had at least one form of epicardial VT.
Nd:YAG laser photocoagulation of myocardial VT using a sequential approach is a viable method that permits an ongoing study of this entity. Operative mortality remains high in patients with diffusely poor left ventricular function. Epicardial VT is frequent in patients with inferior infarcts and may account for inferior results in these patients when conventional endocardial approaches are used alone.
因冠状动脉疾病导致的耐药性室性心动过速（VT）进行确定性治疗的定向手术具有显著的手术死亡率。手术未能治愈VT仍是一个问题，尤其是在没有左心室前壁心肌梗死和动脉瘤的患者中。已开发出一种方法，其中使用钕钇铝石榴石（Nd:YAG）激光通过“序贯”方法对引发VT的心肌进行光凝，旨在改善手术效果并深入了解导致VT的可变基质。
在常温体外循环下，诱发VT，然后进行广泛的心内膜和心外膜标测以定位和表征该形式的VT。将Nd:YAG应用于该形式VT起源的心肌区域，直至其消失且不再可诱发。接下来尝试诱发其他形式的VT，成功后，重复标测和激光治疗，直至最终VT不再可诱发。
51例患者接受了手术并至少随访1年。术前射血分数低于20%的12例患者手术死亡率为41%；射血分数大于20%的39例患者手术死亡率为8%。43例手术幸存者中有88%在1年时无复发性持续性VT。无心律失常死亡病例。在一组评估心外膜VT的30例患者中，14例下壁梗死且无左心室动脉瘤的患者中有9例至少有一种心外膜VT形式。
使用序贯方法对心肌VT进行Nd:YAG激光光凝是一种可行的方法，可对该实体进行持续研究。左心室功能普遍较差的患者手术死亡率仍然很高。下壁梗死患者心外膜VT很常见，单独使用传统的心内膜方法时可能导致这些患者的治疗效果较差。
