Management of sudden cardiac death survivors. Role of surgical and catheter ablation.

Ventricular tachyarrhythmias are the most common arrhythmias documented at the time of sudden cardiac death. Since pharmacological therapy often does not completely suppress these arrhythmias, surgical procedures have been developed to provide an alternative mode of therapy. Coronary artery revascularization in patients with ischemic heart disease is associated with decreased sudden death mortality in patients with left ventricular dysfunction who have no history of prior cardiac arrest or ventricular tachycardia. In sudden death survivors, coronary revascularization appears effective chiefly for patients without inducible ventricular tachycardia or with inducible ventricular fibrillation. Cardiac arrest survivors with sustained monomorphic ventricular tachycardia at electrophysiological study require an ablative procedure that is usually guided by electrophysiological mapping. Current technique should permit elective operations to be carried out with a less than 10% mortality and a greater than 85% rate for suppressing ventricular tachycardia. Nonsurgical catheter ablation techniques have already shown promise in patients with slower, well-tolerated tachycardias that allow extensive catheter mapping. Application of these techniques in patients with the rapid tachycardias associated with sudden death has, to date, been very limited, but as catheter mapping and energy delivery techniques continue to evolve, they may be feasible even in these patients.