Encircling endocardial resection with complete removal of endocardial scar without intraoperative mapping for the ablation of drug-resistant ventricular tachycardia.

Encircling endocardial resection, with complete removal of endocardial scar unguided by intraoperative mapping, was employed in 10 patients with drug-resistant sustained ventricular tachycardia. Reproducible sustained ventricular tachycardia was induced in all patients preoperatively with programmed electrical stimulation. A trial of conventional antiarrhythmics had failed in all 10 patients; seven patients required frequent cardioversion, and three patients required overdrive suppression with temporary transvenous pacing. Encircling endocardial resection was performed in all patients, with complete removal of endocardial scar; partial reimplantation of the mitral apparatus was required in nine patients. Eight patients underwent aneurysmectomy, and the nine patients who required concomitant aorta-coronary bypass received a total of 13 grafts (mean 1.3 grafts per patient). There were no spontaneous postoperative arrhythmias. One patient without postoperative clinical arrhythmias, who had required daily preoperative cardioversion, had inducible ventricular tachycardia with postoperative programmed electrical stimulation, but not after loading with procainamide. Mean follow-up was 17.3 months. Eight patients are alive and well. There were two late deaths. One patient died with recurrent ventricular septal defects 2.5 months following extensive septal encircling endocardial resection, and one patient was readmitted after 4 months with massive pulmonary embolus and right-sided heart failure. This early experience suggests that this procedure, with complete removal of endocardial scar, successfully ablates reentrant ventricular tachycardia. We believe that the procedure will prove to be more effective than localized endocardial resection because the encircling procedure removes all ventricular sites that have the potential to generate reentrant ventricular tachycardia.