A history of collaboration between electrophysiologists and arrhythmia surgeons

Figures

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  Figure 1. This photo of Professor Durk Durrer, the “Father of Clinical Electrophysiology” was taken by his visitor and pupil, Dr. John P. Boineau, as Professor Durrer leaned out the window of a windmill just outside Amsterdam in the summer of 1963

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  Figure 2. The first definitive proof by Boineau and Moore that accessory AV pathways are responsible for the intermittent tachycardia associated with the WPW syndrome. See text for further discussion. AV, atrio‐ventricular; WPW, Wolff‐Parkinson‐White.

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  Figure 3. The epicardial map recorded by Burchell during MaGoon's surgery for an atrial septal defect. The large numbers are for location identification only. The smaller numbers indicate that the earliest site of pre‐excitation is at the extreme lateral portion of the right atrio‐ventricular (AV) groove. This was the first successful attempt to localize an accessory AV connection in a patient at surgery. Lidocaine was injected at the suspected site of the pathway, resulting in temporary elimination of the ventricular pre‐excitation. See text for further discussion. (Reproduced by permission from Reference 6 ).

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  Figure 4. Left panel: Dr. Will C. Sealy, the arrhythmia surgeon, and Dr. John Boineau, the primary electrophysiologist involved in the first successful intraoperative mapping and surgical division of an accessory atrio‐ventricular (AV) connection responsible for the Wolff‐Parkinson‐White syndrome. Right panel: Title page of the paper describing this first surgical procedure and an operative photo of the heart after the right AV groove dissection had been performed. (Reproduced by permission from Reference 6 ).

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  Figure 5. Photo of members of the Basic Science Electrophysiology Laboratory at Duke University showing the collaboration of an aspiring cardiac arrhythmia surgeon still in training and a young pioneer in cardiac electrophysiology, the brilliant John Boineau

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  Figure 6. Upper panel: Anatomic illustrations of the appearance of a left ventricular aneurysm and the standard resection of that aneurysm performed by surgeons in the late 1970s. Note that the endocardial scar extends further toward the base of the heart than does the epicardial scar. Unfortunately, the micro‐reentrant circuits that induce ischemic ventricular tachycardia (VT) occur primarily at the junction of the endocardial scar with normal myocardium. Thus, in a standard left ventricle (LV) aneurysm resection, those micro‐reentrant circuits are left behind and can still lead to the arrhythmia. Lower panel: Anatomic illustrations of three surgical procedures developed specifically to ablate ischemic VT following LV aneurysm resection. The collaborating arrhythmia surgeons and electrophysiologists who worked extremely closely to develop and implement these procedures are listed.

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  Figure 7. Analog mapping system: Examples of the different electrode arrays developed to map ventricular tachycardia (VT). The sock electrode contained 32 bipolar electrodes that allowed multipoint analog mapping of the epicardium during induced VT. Only 16 analog channels could be recorded at one time, so a toggle switch was incorporated to record the anterior 16 electrograms and the 16 posterior electrograms as quickly as possible. The egg electrode contained 12 bipolar strip electrodes on the outer surface of one‐half of a plastic toy egg. The narrow end of the toy egg was inserted directly into an open left ventricle aneurysm and circumferential endocardial maps were performed during both sinus rhythm and induced VT. Form‐fitting silastic endocardial electrode arrays were constructed for both ventricles. Transmural mapping of the ventricles was possible using intramural needle electrodes. These 0.23‐guage needles contained fixed electrodes every 0.5 mm along the needle shaft.

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  Figure 8. Left upper panel: Shape of an incision made to isolate a portion of the right ventricular outflow tract (RVOT) and supra‐cristal septum. The two ends of the incision are anchored on the nonconductive pulmonary valve annulus. Right upper panel: Illustration showing a “flap” of the right ventricular free‐wall based on the right coronary artery and atrio‐ventricular groove that was performed in a 66 year‐old male with arrhythmogenic right ventricular dysplasia (ARVD). An incision was extended to a small, thin aneurysm near the right ventricle (RV) apex from which some of the runs of VT were originating. Left lower panel: Illustration showing how the right ventricular free‐wall was totally disconnected from the rest of the heart with only two incisions, one long and one short. The two ends of each incision are anchored on nonconductive tissue of the pulmonary and tricuspid valve annuli. Right lower panel: Illustration showing several leads of the standard electrocardiogram and also electrograms recorded directly from the right atrium (RA), RV, and left ventricle (LV). The tachycardia is confined exclusively to the isolated RV free‐wall, but activation of the RA and LV prove that the…

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  Figure 9. Electrode arrays for Computerized Mapping of experimental atrial fibrillation. Left panel: 3‐dimensional (3‐D) silastic mold electrode arrays that made it possible to perform 3‐D mapping of atrial fibrillation in dogs for the first time. Right panel: Images taken from a video of experimental atrial fibrillation in which the 3‐D electrode array data were superimposed on the reconstructed 3‐D image of the animal's atria from gated magnetic resonance imaging scans. This particular map was recorded in 1987.

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  Figure 10. Mapping of human atrial fibrillation, c. 1987. Left panel: Electrode arrays with a total of 156 bipolar electrodes in three separate silastic sheets. They are shaped to cover (A) the anterior‐superior epicardial surfaces of both atria, (B) the posterior−inferior epicardial surfaces of both atria, and (C) the right atrial free‐wall epicardial surface. Septal electrode arrays were added later. Right panel: The first ever multipoint, global computerized map of human atrial fibrillation. For purposes of illustrating 3‐dimensional data in a 2‐dimensional format, imagine that a saggital section across both atria has been made and you are viewing the atria from the posterior view with the anterior half of the atria “flipped” up so that the electrical events there can be seen. Note that there are two macro‐reentrant circuits present, one in the left atrial isthmus and a larger one utilizing the right atrial free‐wall and atrial septum. LAA, left ‐atrial appendage; M, mitral valve orifice; PV, pulmonary veins; RAA, right atrial appendage; SVC, superior vena cava; T, tricuspid valve orifice.

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  Figure 11. A 50+ year time‐line showing the year that each of the major surgical procedures and catheter ablation procedures were first performed for the specific arrhythmias listed. Inset: Chart showing the delay in time between the application of the surgical procedure and catheter ablation for the same clinical arrhythmia. AAT, automatic atrial tachycardias; AF = atrial fibrillation; AVNRT, atrio‐ventricular node reentrant tachycardia; VT, ventricular tachycardia; WPW, Wolff‐Parkinson‐White syndrome.

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  Figure 12. Combination of time‐line of the evolution of interventional therapy for cardiac arrhythmias, the seminal events that occurred to change that therapy, what those changes were in terms of procedures, and suggestion of the level of collaboration between electrophysiologists and arrhythmia surgeons during each period (the central horizontal red lines). See text for further discussion. AF, atrial fibrillation; ARVD, arrhythmogenic right ventricular dysplasia; AVNRT, atrio‐ventricular node reentrant tachycardia; PVI, pulmonary vein isolation; WPW, Wolff‐Parkinson‐White syndrome.