**9. Summary and message**

Whenever a typical early potential is detected by the electrophysiologist, lasing is performed with the gas cooled fiber kept at a distance of approximately 5mm away from the tissue. So a sufficiently deep lesion can be created without removal of tissue and distruction of the structural integrity of the myocardium. Laser application is terminated after the VT stops and sinus rhythm reoccures. This procedure is repeated on the endo- and afterwards on the epicardium, until no further VT is inducible. After that, surgery is continued in the normal fashion with the definitive aneurysm resection, ventricular restoration and bypass surgery. If no aneurysm is present, the ventricle is generally not opened but mapping guided laser photocoagulation only performed epicardially. If in these cases no further epicardial focus can be mapped but a VT, mostly different to the initial clinical recording, is still inducible, the procedure must be terminated without complete cure, as already described above. According

to our very strict protocol, all these patients receive an ICD in a second intervention.

(a) (b)

**Figure 2.** Intraoperative mapping with a small fingerprobe (a) and laser photocoagulation with protective gogles (b)

Postoperatively, no antiarrhythmic drugs are given, except the standard medication with a beta-blocker. Before discharge, every patient is submitted to a final electrophysiological investigation with an aggressive stimulation protocol to induce an arrhythmia. The photocoa‐ gulation is only considered successful, if no ventricular arrhythmia can be induced including VT´s different from the initial one or even Vfib. Patients with any type of inducible arrhythmia

Depending of course on the number of foci mapped and photocoagulated, the operative procedure is prolonged for about half an hour. The heart is not arrested during this time, so

**7. Postoperative protocol**

get an ICD before being discharged.

**8. Results**

40 Artery Bypass

In contrast to Vfib, Vt is in the vast majority of cases associated with a clearly defined patho‐ anatomical substrate, an inhomogenious interdentation of scar and vital myocardium in the border zone of a postinfarct scar, which is not affected by revascularization, but has to be adressed separately.

Revascularization alone will not lead to termination of Vt´s, nor will sole resection of scar or an aneurysm be curative either, as the inhomogenious borderzone remains unaf‐ fected and may still trigger reentry circuits, which may be located subendocardially as well as subepicardially.

As a consequence, any patient with a documented VT and an indication for surgical revascu‐ larization and / or a ventricular restoration should also be submitted to an intraoperative VT ablation and be referred to specialized centers. A surgical intervention should always aim at curative result and ICD is very effective but is palliative!
