Surgical Management of Sustained Ventricular Arrhythmias Presenting within Eight Weeks of Acute Myocardial Infarction

When it occurs after a recent (less than eight weeks) myocardial infarction, sustained ventricular tachycardia (VT) or fibrillation (VF) has resulted in a high one-year mortality despite antiarrhythmic drug therapy. We have operated on 29 patients with this syndrome either on an emergency basis because they had medically refractory VT or VF (19 patients) or electively if they had persistent congestive heart failure or angina and VT or VF (10 patients). Ages ranged from 36 to 82 years (mean, 60 years), and the mean left ventricular ejection fraction was 31 ± 13%. Each patient had failed a trial of one or more (average, four) antiarrhythmic drugs and because of VT, required electrical cardioversion on an average of five occasions. Intraoperative mapping was complicated by multiple VT morphologies (9 patients), the rapid degeneration of VT to VF (5 patients), and the inability to induce VT reliably (5 patients). Subendocardial excision was performed at the site of the earliest electrical activity, or if no single site could be identified, a wide subendocardial excision of all visible scar was performed. There were 4 perioperative deaths (14%). All operative survivors underwent postoperative electrophysiological studies. Twenty of them required no further antiarrhythmic therapy, but 5 patients required drug therapy because of either spontaneous (2 patients) or electrically induced (3 patients) VT. During follow-up (average, 16 months) of these 25 patients, there have been 3 late deaths, 2 of them sudden. Two of the 3 late deaths were those of patients taking antiarrhythmic drugs. Our results demonstrate the effectiveness of early operative intervention when sustained ventricular arrhythmias complicate recovery after myocardial infarction. Satisfactory results can be obtained using an aggressive operative approach.