COMMENT
Non-ischemic cardiomyopathy (NICM) is a heterogenous group of direct myocardial dysfunction stemming from a wide range of pathologies. Dilated NICM was traditionally treated medically and often culminated in heart transplant for patients at the end stage (1). As for surgical options, partial left ventriculectomy (PLV) was proposed and performed sporadically primarily by Dr. Batista. Due to lack of accurate diagnosis techniques such as the contemporary intraoperative echocardiographic studies to identify the predominant region of myocardial involvement, PLV was associated with inconsistent results and thus left ventricular reconstruction in this population of patients was abandoned all together (2). The poor outcomes from the PLV in dilated NICM was believed to stem from the variability in myocardial distribution in this non-homogenous group of cardiomyopathy and thus the risk of excluding healthy segments (3). Therefore, the outdated “one size fit all” approach with PLV was noted to be ineffective in the surgical management of dilated NICM. This observation has prompted the initiation of targeted surgical approaches that only exclude the most affected regions. In fact, PLV remains an option reserved for lateral wall involvement. However, when septal damage is the most culprit area, a technique developed by Dr. Torrent-Guasp, termed Septal Anterior Ventricular Exclusion (SAVE) was developed to exclude the septum with the insertion of an oblique patch between the apex and high septum, just below the aortic valve with subsequent closure of the excluded wall over the patch (4). This technique acts in a fashion similar to the more circular patch used to exclude the apical wall in the Dor procedure that has been heavily used in the treatment of ischemic cardiomyopathy to reconstruct the LV (5).
In 2003, Mickleborough et al. published their experience of LV reconstruction in 108 patients with ischemic cardiomyopathy and preoperative VT which were treated with direct visual endocardial excision and peripheral cryoablation. The post-operative freedom from VT or sudden death was found to be 99%, 97%, and 94% at 1, 5, and 10 years, respectively. This study however only focused on patients who developed aneurysmal changes to their left ventricle following myocardial infarction.
In this report, we describe a successful surgical treatment of a patient who presented with a heavily calcified apical left ventricular aneurysm secondary to non-ischemic cardiomyopathy in conjunction with prolonged VT that has failed medical management and was unamenable to previous endocardial or epicardial ablation. We believed that performing a Dor procedure would exclude the LV apex that was the most diseased and akinetic myocardial segment. We also opted to use CryoFlex Probe to ablate on the area of arrhythmia generation endo- and epicardially to achieve a transmural isolation to control the patient intractable VT. The patient had an uneventful course with resolution of his ventricular tachycardia and was discharge home on the 6thpost-operative day with normalized LVEF and freedom from any recurrent VT.