CRP6.Concomitant Ventricular Reconstruction with Endoventricular Circular Plasty (Dor procedure) and Cryoablation for Refractory Ventricular Tachycardia
Presented During: AATS Cardiothoracic Resident Case Report-Poster Display
Mayo Clinic
United States - Contact Me
Chief resident in the Thoracic and Cardiac surgery training program at Mayo Clinic in Rochester, Minnesota. I am board certified by the American Board of Surgery and will be board eligible for the American Board of Thoracic Surgery in 2023.
Incoming University of Michigan Advanced Aortic Fellow, August 2023-2024.
My clinical interests revolve around aortic disease, including aortic valve repair, valve sparing procedures, the Ross procedure, aortic arch, and endovascular interventions however I have a passion for adult cardiac surgery as a whole.
Saturday, May 6, 2023: 5:00 PM - Tuesday, May 9, 2023: 5:00 PM
Los Angeles Convention Center
Room: ePoster Area, Exhibit Hall
Description
Objective: Reconstruction of left ventricular (LV) geometry for ischemic cardiomyopathy following myocardial infarction was first described by Vincent Dor in 1984. Here we describe the concomitant management of a LV aneurysm and refractory non-sustained ventricular tachycardia.
Methods: A 50-year-old woman with a history of Noonan syndrome, presented with multiple ST elevation myocardial infarctions requiring stenting to the left anterior descending (LAD) in 2016, then mid-LAD, 1st diagonal, and proximal right coronary artery in 2021, and subsequently to the circumflex artery in 2022. Since then, she has developed non-sustained ventricular tachycardia (VT) requiring two unsuccessful percutaneous VT ablations, and implantable cardioverter defibrillator placement. She presented with shortness of breath, fatigue, lower extremity edema, and poor functional status. Echocardiogram demonstrated a very large apical LV aneurysm. Cardiac magnetic resonance imaging (MRI) confirmed the apical aneurysm with transmural scar. Simulation of the LV aneurysm resection by MRI, showed an increased LV ejection fraction from 36% to 49% with reduction in LV end diastolic volume from 206 cc to 111 cc. LV reconstruction with VT ablation was chosen as intervention, it was determined that there was no need for concomitant revascularization. Cardiopulmonary bypass was initiated via aortic and right atrial cannulation. Mapping was performed on cardiopulmonary bypass noting foci of inducible arrhythmogenic tissue within the aneurysmal LV wall (Figure 1A). In performing LV reconstruction with endoventricular circular plasty, these foci would be preserved. We therefore elected to perform a cryoablation circumferentially at the transitional zone of the LV aneurysm from both the endocardial and epicardial approach to allow for transmural ablation (Figure 1B). Completion of LV reconstruction with endoventricular circular plasty was performed with interrupted pledgeted sutures at the transition zone, the patch was sized, and tied in place. The incised aneurysmal apex was reapproximated with permanent suture and reinforced with felt strips (Figure 1C-D). Post operatively the patient was maintained on home dose antiarrhythmics without any documented arrhythmias. She discharged on post operative day 7 and has been recovering without arrhythmias.
Results: LV reconstruction utilizing exclusion technique of noncontractile aneurysmal regions of LV to restore size and shape has been associated with improved outcomes. The addition of ablation with intraoperative mapping of arrhythmogenic foci allows for transmural cryoablation with both endocardial and epicardial approaches. This patient has been arrhythmia free since the intervention, with two prior failed attempts at percutaneous ablation we feel that transmural ablation is the key to success.
Conclusions: Left ventricular aneurysm with refractory ventricular tachycardia can be treated successfully and safely with concomitant left ventricular reconstruction and transmural cryoablation.
Methods: A 50-year-old woman with a history of Noonan syndrome, presented with multiple ST elevation myocardial infarctions requiring stenting to the left anterior descending (LAD) in 2016, then mid-LAD, 1st diagonal, and proximal right coronary artery in 2021, and subsequently to the circumflex artery in 2022. Since then, she has developed non-sustained ventricular tachycardia (VT) requiring two unsuccessful percutaneous VT ablations, and implantable cardioverter defibrillator placement. She presented with shortness of breath, fatigue, lower extremity edema, and poor functional status. Echocardiogram demonstrated a very large apical LV aneurysm. Cardiac magnetic resonance imaging (MRI) confirmed the apical aneurysm with transmural scar. Simulation of the LV aneurysm resection by MRI, showed an increased LV ejection fraction from 36% to 49% with reduction in LV end diastolic volume from 206 cc to 111 cc. LV reconstruction with VT ablation was chosen as intervention, it was determined that there was no need for concomitant revascularization. Cardiopulmonary bypass was initiated via aortic and right atrial cannulation. Mapping was performed on cardiopulmonary bypass noting foci of inducible arrhythmogenic tissue within the aneurysmal LV wall (Figure 1A). In performing LV reconstruction with endoventricular circular plasty, these foci would be preserved. We therefore elected to perform a cryoablation circumferentially at the transitional zone of the LV aneurysm from both the endocardial and epicardial approach to allow for transmural ablation (Figure 1B). Completion of LV reconstruction with endoventricular circular plasty was performed with interrupted pledgeted sutures at the transition zone, the patch was sized, and tied in place. The incised aneurysmal apex was reapproximated with permanent suture and reinforced with felt strips (Figure 1C-D). Post operatively the patient was maintained on home dose antiarrhythmics without any documented arrhythmias. She discharged on post operative day 7 and has been recovering without arrhythmias.
Results: LV reconstruction utilizing exclusion technique of noncontractile aneurysmal regions of LV to restore size and shape has been associated with improved outcomes. The addition of ablation with intraoperative mapping of arrhythmogenic foci allows for transmural cryoablation with both endocardial and epicardial approaches. This patient has been arrhythmia free since the intervention, with two prior failed attempts at percutaneous ablation we feel that transmural ablation is the key to success.
Conclusions: Left ventricular aneurysm with refractory ventricular tachycardia can be treated successfully and safely with concomitant left ventricular reconstruction and transmural cryoablation.