Subendocardial resection and implantation of an automatic
implantable cardioverter/defibrillator are the current preferred treatments for the management of
drug-resistant malignant ventricular arrhythmias and
sudden cardiac death. We reviewed retrospectively the case histories of 269 patients who had subendocardial resection and 77 patients who had
defibrillator implantation to define clinical characteristics of each group and compare operative and long-term results. All patients treated by subendocardial resection had recurrent sustained
ventricular tachycardia as a result of a
myocardial infarction. From the standpoint of
arrhythmia substrate and
cardiac disease, patients receiving the
defibrillator were a more heterogeneous group. Forty-eight (62%) had
coronary artery disease, 28 (36%)
cardiomyopathy, and one patient had a primary electrical abnormality. Among patients receiving the
defibrillator, 55% had sustained
ventricular tachycardia and 45% polymorphic
ventricular tachycardia or
ventricular fibrillation. Overall ventricular function was similar in the two groups. Operative mortality rate was better in the group having
defibrillator implantation (3% versus 15%). Complications related to the
defibrillator device or implantation occurred in 46 (60%) patients, with asymptomatic shocks occurring in 35 patients (45%). Since the
defibrillator was not designed to prevent arrhythmias, the
arrhythmia-free survival rate was much better in the group having subendocardial resection (95% versus 44% at 3 years). Fewer patients treated by subendocardial resection required antiarrhythmic medications (33% versus 66%). The actuarial survival rate was similar in the two groups (approximately 60% at 4 years), with
heart failure the most common cause of death. Thus both subendocardial resection and
defibrillator implantation are highly effective in preventing
sudden cardiac death. The choice of procedure depends on (1)
arrhythmia diagnosis, (2)
cardiac disease, and (3) intangible factors.