Intraoperative mapping and surgery for the prevention of lethal arrhythmias after myocardial infarction

Effects of simulated intraoperative electrophysiological testing on function of the canine left ventricle

With the increasing application of arrhythmia surgery, intraoperative electrophysiological study is done frequently, although its potential to cause acute depression of cardiac function remains unresolved. This study examines the acute effects of simulated electrophysiological testing on left ventricular function. Seven dogs were anesthetized with sodium pentobarbital and instrumented for measurement of heart rate, mean aortic pressure, cardiac output (CO), and systemic vascular resistance (SVR). Systolic pressure-dimension work loops were analyzed over varying preloads. Contractility was assessed from the end-systolic pressure-dimension relationship (Ees) and from preload recruitable stroke work (PRSW). After the collection of control data, electrophysiological testing was simulated by pacing at 200 beats per minute for 30 seconds, fibrillating for 15 seconds, and finally defibrillating with a 10-J countershock. Data were recorded after 3 and 6 simulations of ventricular fibrillation (VF3, VF6). Mean heart rate and mean aortic pressure did not vary significantly during the course of the experiment. CO decreased from a control value of 2.7 +/- 0.2 L/min (+/- the standard error of the mean) to 2.0 +/- 0.1 (p less than 0.05) after VF3 and remained significantly depressed after VF6. SVR increased from a control value of 3,231 +/- 211 dyne sec cm-5 to 3,976 +/- 305 dyne sec cm-5 after VF3 (p = not significant) and increased further to 4,774 +/- 442 dyne sec cm-5 after VF6 (p less than 0.05). Neither Ees nor PRSW varied significantly even after 6 EP simulations, thereby indicating that contractility was unchanged during the experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

When is myocardial mapping clinically valuable?

All cardiac arrhythmias are either automatic or reentrant. Automatic arrhythmias occur in the periinfarction or perioperative period. Chronic, recurrent arrhythmias are typically reentrant. By definition, reentrant arrhythmias are inducible with programmed electrical stimulation. When a malignant cardiac arrhythmia is identified, the patient is taken to the electrophysiologic laboratory for study. Reentrant ventricular tachyarrhythmias are induced with programmed electrical stimulation. Pharmacologic suppression is guided by electrophysiologic testing. When antiarrhythmic suppression fails, surgical intervention may be an effective alternative. Endocardial catheter mapping before surgery may serve as an important guide to the surgeon. Myocardial mapping is clinically valuable only when all antiarrhythmic therapy has failed, and the patient is considered to be a candidate for surgical intervention. When surgical intervention is planned, we consider preoperative catheter mapping desirable and intraoperative electrophysiologic localization mandatory.