Extended subendocardial resection. A surgical approach to ventricular tachyarrhythmias that cannot be mapped intraoperatively.

The optimal surgical management of patients with sustained, uniform-morphology ventricular tachycardia is endocardial activation sequence mapping during ventricular tachycardia and directed resection and/or cryoablation of the involved endocardium. The results of these procedures are superior to those obtained with nondirected aneurysmectomy. The optimal operative procedure when stable uniform ventricular tachycardia cannot be induced intraoperatively is uncertain. Between April, 1982, and April, 1984, intraoperative endocardial mapping was attempted on 33 patients with prior ventricular tachycardia. There were six perioperative deaths. Completely satisfactory intraoperative electrophysiologic maps were obtained in only 17 of the remaining 27 patients (63%). In 10 of these 27 patients, stable ventricular tachycardia could not be induced in the operating room, and satisfactory mapping thus could not be performed. In the first three of these 10 patients, limited subendocardial resection was performed either in regions with fractionated activity during sinus rhythm (two patients) or in regions suggested by preoperative catheter mapping (one patient). Ventricular tachycardia recurred postoperatively in two of these three patients. In the next seven patients, all visible endocardial scar around the border of the aneurysm was resected. Clinical ventricular tachycardia could not be induced at postoperative electrophysiologic study and has not recurred in these seven patients. These results suggest that complete endocardial resection provides an acceptable operative approach when intraoperative electrophysiologic mapping is not satisfactory.