Operative risks and long-term results of operation for left ventricular aneurysm

Left Ventricular Aneurysmectomy: Tailored Scar Excision and Linear Closure

Coronary artery bypass surgery with or without aneurysmectomy is used to treat patients with left ventricular aneurysm. There is debate about patient selection and the appropriate surgical technique. We analyzed the results of 102 consecutive patients who underwent left ventricular aneurysmectomy and reconstruction using a modified linear closure technique between 1992 and 2003. The mean age was 62 years, 81% of the patients were male, and 47% had an ejection fraction < 35%. The locations of the left ventricular aneurysms were anteroapical (75%), apical (21%), and posteroinferior (4%); 23% contained thrombi. Additional procedures included aortic valve replacement in 4, mitral valve repair in 1, and coronary bypass grafting in 98 patients; 3 underwent isolated repair of left ventricular aneurysm. Hospital mortality was 7% and long-term survival was 76% at a mean follow-up of 39 months. Most patients improved symptomatically postoperatively. Left ventricular aneurysm repair with tailored scar excision and a modified closure technique is associated with acceptable mortality and long-term survival.

Ruptured left ventricular false aneurysm following acute myocardial infarction: case report and review of the literature

False aneurysms of the left ventricle complicating acute myocardial infarction are rare. Given they are only contained by pericardial adhesions, they are prone to rupture and hence surgical repair is mandatory. We report a successful repair of a ruptured false aneurysm and then briefly review the current literature.

Left ventricular aneurysm repair with use of a bovine pericardial patch

Left ventricular aneurysm, which can impair systolic function, has a reported incidence of 10% to 35% in patients after myocardial infarction. In a 58-year-old woman who had a history of myocardial infarction, we excised a large left ventricular aneurysm and restored left ventricular geometry with use of a bovine pericardial patch. The aneurysm's characteristics and the patient's preoperative left ventricular ejection fraction of 0.25 had indicated surgical intervention. The patient had an uneventful postoperative course, and her left ventricular ejection fraction was 0.50 to 0.55 on the 4th postoperative day. This case illustrates the value of surgical treatment for patients who have a debilitating left ventricular aneurysm.

Cardiac aneurysm: a nature's way of correction

Cardiac aneurysm occurring in ventricles is usually a complication of acute transmural myocardial infarction. The development of cardiac aneurysm represents a process of continued thinning and fibrosis of the necrotic tissue of the ventricular wall. Survival of the person without any complication depends on the development of the solid fibrous scar, which seals the aneurysmal cavity.We present an incidental case wherein a person survived with a ventricular aneurysm that sealed itself by natural means due to the development of a thrombus and fibrous tissue offering a natural protection. The person died because of head injury in a road traffic accident in this particular case.

Off-pump anteroapical aneurysm plication following left ventricular postinfarction aneurysm: effect on cardiac function, clinical status and survival

BACKGROUND

In patients with coronary disease and aneurysm, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. We report our results with off-pump aneurysm plication after ventricular aneurysm with relative wall thinning.

METHODS

We retrospectively reviewed the records of 248 patients who had an operation for postinfarction left ventricular aneurysm. Reconstruction was accomplished by off-pump anteroapical aneurysm plication. The following variables were recorded: preoperative clinical, angiographic and echocardiographic findings and operative procedures. Outcomes were early mortality, long-term survival and poor 5-year result, defined as the need for transplantation or repeated hospitalization for congestive heart failure. Risk factors were pinpointed using the t test and survival curves. Independent risk factors were identified using Cox regression methods.

RESULTS

Hospital mortality was low (2.0%). Mean follow-up was 5.8 (standard deviation [SD] 3.8) years. Actuarial survival at 1 and 5 years was 94% and 84%. Among the 232 survivors, 200 were in functional class I or II, and the average increase in ejection fraction was 14.0% (SD 3.1%). As determined by multivariable analysis, factors predicting poor outcome were advanced age, ejection fraction less than 0.35, conicity index less than 1, end-systolic volume index greater than 80 mL/m2, advanced New York Heart Association functional class and congestive heart failure.

CONCLUSION

Using wall thinning as a criterion for patient selection, the technique of off-pump anteroapical aneurysm plication can be performed with low operative mortality and provides good symptomatic relief and long-term survival.

Long-term outcomes after surgical ventricular restoration and coronary artery bypass grafting in patients with postinfarction left ventricular anterior aneurysm

OBJECTIVE

Surgical ventricular restoration (SVR) for postinfarction left ventricular anterior aneurysm improves left ventricular function. The aim of this study was to evaluate whether concomitant multivessel coronary artery disease (MVCAD) can affect long-term outcome. Thus, long-term results of SVR associated with multiple coronary artery bypass grafting (CABG) for MVCAD (group 1) were compared with SVR with or without CABG to left anterior descending artery and/or its diagonal branch for single-vessel coronary artery disease (group 2).

METHODS

Data from 104 consecutive patients (age 64 +/- 8 years) with left ventricular anterior aneurysm, subjected to SVR from January 1994 to December 2004 and divided into group 1 (n = 79) and group 2 (n = 25), were analyzed.

RESULTS

In group 1 vs. group 2, number of grafts/patient (2.7 +/- 0.9 vs. 0.6 +/- 0.6, P < 0.0001) was higher, cardiopulmonary bypass (109 +/- 30 vs. 65 +/- 28 min, P < 0.0001) and aortic cross-clamp times (65 +/- 18 vs. 44 +/- 23 min, P < 0.0001) were longer, resected aneurysmatic area (12 +/- 8 vs. 17 +/- 11 cm2, P < 0.05) was smaller. Operative mortality was 3.7 vs. 4% (P = not significant). At 12 years, survival (85 +/- 5 vs. 80 +/- 16%) and freedom from cardiac events (70 +/- 7 vs. 75 +/- 16%) were not statistically different in both groups. Follow-up echocardiography showed significant left ventricular ejection fraction improvement in group 1 (0.45 +/- 0.07 vs. 0.34 +/- 0.10 preoperatively, P < 0.0001) and group 2 (0.47 +/- 0.09 vs. 0.36 +/- 0.12, P = 0.001). Independent predictors of late death were preoperative history of ventricular arrhythmias (P < 0.001) and hypo/akinesia of proximal myocardial anterior wall (P < 0.05).

CONCLUSION

Late survival and freedom from cardiac events are excellent after SVR, also when concomitant MVCAD requires complete revascularization. Ventricular arrhythmias and impaired left ventricular anterior wall function are predictors of worse outcome.

Surgical treatment of left ventricular aneurysm

When a left ventricular aneurysm leads to pulmonary congestive symptoms, aneurysmectomy may provide relief. This retrospective study included 269 patients who underwent aneurysmectomy between 1993 and 2002, by the classic Cooley operation in 164 and by Dor ventriculoplasty in 105. There were no significant differences in early and late survival between groups, although the frequency of extended anteroseptal infarction was higher in patients undergoing the Dor procedure. Postoperative echocardiographic findings showed significant improvements in left ventricular function in both groups, in terms of end-diastolic and end-systolic dimensions and ejection fraction. Left ventricular aneurysmectomy significantly improved the clinical status and hemodynamic parameters of symptomatic patients. The choice of surgical technique depends on the extent of the scar segment, especially the presence of an anteroseptal scarred area. The Dor procedure is more suitable for restoring normal left ventricular geometry in patients with extensive septal infarction.

Left ventricular aneurysm repair: a comparison of linear versus patch remodeling

BACKGROUND

Surgical repair of left ventricular (LV) aneurysm has been performed for around 50 years. However, the most appropriate surgical approach remains undetermined. This study was undertaken to compare the efficacy of 2 established techniques, linear versus patch remodeling, for repair of dyskinetic LV aneurysms.

METHODS

We retrospectively reviewed the records of 49 patients (mean age, 69.8 +/- 7.3 years) who had operation for postinfarction dyskinetic LV aneurysm between 1996 and 2006. Thirty-one patients underwent patch remodeling and 18 underwent linear repair. Short-term and mid-term outcomes, including complications, cardiac function and mortality, were assessed.

RESULTS

Overall inhospital surgical mortality, major complications and early hemodynamics showed no significant differences between the 2 groups. During a mean follow-up of 44.0 +/- 34.4 months, 8 patients died, with 4 due to cardiac-related causes. Actuarial survival rates at 1, 5 and 10 years were 85.7%, 69.9% and 45.7%, respectively. Functional class improved from 2.51 +/- 0.59 to 1.66 +/- 0.54 among the mid-term survivors (p < 0.001), with no significant difference between the 2 groups. Multivariate analysis identified preoperative NYHA functional class >or= 3 as an independent risk factor for overall mortality (p = 0.008). Mid-term follow-up revealed that LV ejection fraction improved from 26.5 +/- 7.2% to 34.1 +/- 7.9% (p < 0.001) in the patch group, and from 26.3 +/- 9.0% to 32.0 +/- 9.2% in the linear group (p = 0.032). In contrast, right ventricular ejection fraction improved from 49.4 +/- 10.1% to 52.0 +/- 7.3% (p = 0.190) in the patch group, but deteriorated from 55.0 +/- 6.3% to 50.3 +/- 8.6% in the linear group (p = 0.029).

CONCLUSION

These findings indicate that the 2 repair techniques have similar effectiveness with respect to short- and mid-term outcomes except for right ventricular ejection fraction. We suggest that the selection of repair technique for LV aneurysms should be individualized for each patient based on aneurysm size and extent of the scarring process into the septum and subvalvular mitral apparatus.

Surgery for left ventricular aneurysm: is there still any role for simple linear repair?

The aim of left ventricular aneurysm (LVA) surgery is to eliminate the diskinetic portion of the left ventricle and to restore the patient's clinical condition. This can be obtained with two surgical procedures: linear repair and endoventricular patch technique. We investigated early- and long-term results in patients who underwent both procedures. From January 1980 to December 2004, 158 patients underwent surgical repair of LVA: 86 had linear repair and 72 patch repair. Operative mortality was 6.9%, with no differences between the two groups. Logistic regression revealed older age, higher left ventricular end-diastolic volume, and an ejection fraction (EF) less than 30% as independent risk factors for in-hospital mortality; the type of operation "per se" did not influence the early mortality. At the follow-up extending up to 25 years, there was no statistically significant difference in survival between the two study groups, as well as in New York Heart Association and Canadian Cardiovascular Society classes. Cox regression revealed older age, EF less than 30%, urgent operation, and a history of cerebrovascular accident as independent risk factors for late mortality: the type of operation did not influence mortality at follow-up. We conclude that aneurysm resection associated with myocardial revascularization is the best treatment for LVA. The choice of the technique should be tailored on an individual basis, according to aneurism location, extension, residual ventricular function, and septal involvement.

Left ventricular aneurysm in patients with previous cardiac surgery

Left ventricular aneurysm in patients who have undergone previous cardiac surgery is infrequently reported. We reviewed the results in all patients treated for left ventricular aneurysm between 1983 and 1995 at St. Vincent Hospital and Medical Center. Of 109 patients undergoing left ventricular aneurysm surgery, 10 had open heart surgery an average of 8.9 years previously. There was no mortality or significant morbidity in those who had previous operations. Functional status improved significantly after surgery. We concluded that surgical treatment of left ventricular aneurysm in patients who had previous open heart surgery can be performed with acceptable risks and leads to functional improvement.

Surgery of left ventricular aneurysm: a meta-analysis of early outcomes following different reconstruction techniques

BACKGROUND

The purpose of this study is to assess the effects of linear and geometric left ventricular aneurysm reconstruction on early postoperative outcomes.

METHODS

A search of computerized databases supplemented with manual bibliographic review was performed for all peer-reviewed English language publications concerning randomized and nonrandomized studies reporting the results of left ventricular reconstruction after both linear and geometric reconstruction techniques. Meta-analyses of several short-term outcomes were performed.

RESULTS

No randomized trial was identified. Eighteen nonrandomized trials were found with a total of 1,814 and 803 patients who underwent linear and geometric reconstruction, respectively. Meta-analysis of all studies (n = 18) revealed an increased risk of in-hospital death for patients undergoing linear reconstruction (relative risk = 1.59, 95% confidence interval: 1.12 to 2.26, p = 0.01). The subanalysis of studies in which linear reconstruction was adopted mainly in the first period of time, and geometric reconstruction was adopted in a later phase, still showed a significant advantage in terms of in-hospital mortality for patients undergoing geometric reconstruction (n = 11 studies, relative risk = 1.89, 95% confidence interval: 1.22 to 2.93, p = 0.004). By contrast, when the two surgical approaches were carried out in the same time lag, there was no difference between linear and geometric reconstruction techniques (n = 7 studies, relative risk = 1.04, 95% confidence interval: 0.57 to 1.92, p = 0.89). No differences in the other outcomes of interest were observed.

CONCLUSIONS

The advantage for geometric reconstruction techniques in terms of in-hospital mortality shown in some studies can be an effect of learning curve or of improvement over time in management of these difficult patients. Further studies are required to clarify this issue.

Left ventricle remodelling by double-patch sandwich technique

Background

The sandwich double-patch technique was adopted as an alternative method for reconstruction of the left ventricle after excision of postinfarction dysfunctional myocardium to solve technical problems due to the thick edges of the ventricular wall.

Methods

Over a 5-year period, 12 of 21 patients with postinfarction antero-apical left ventricular aneurysm had thick wall edges after wall excision. It was due to akinetic muscular thick tissue in 6 cases, while in the other 6 with classic fibrous aneurysm, thick edges remained after the cut of the border zone. The ventricular opening was sandwiched between two patches and this is a technique which is currently used for the treatment of the interventricular septum rupture. In our patients the patches are much smaller than the removed aneurysm and they were sutured simply by a single row of single stitches. However, in contrast to interventricular septum rupture where the patches loosen the tension of the tissues, in our patients the patches pull strongly and restrain the walls by fastening their edges and supporting tight stitches. In this way they could narrow the cavity and close the ventricle.

Results

The resected area varied from 5 × 4 to 8 × 8 cm. Excision was extended into the interventricular septum in 5 patients, thus opening the right ventricle. CABG was performed on all patients but two. Left ventricular volumes and the ejection fraction changed significantly: end-systolic volume 93.5 ± 12.4 to 57.8 ± 8.9 ml, p < 0.001; end-diastolic volume 157.2 ± 16.7 to 115.3 ± 14.9 ml, p < 0.001; ejection fraction 40.3 ± 4.2 to 49.5 ± 5.7%, p < 0.001. All patients did well. One patient suffered from bleeding, which was not from the wall suture, and another had a left arm paresis. The post-operative hospital stay was 5 to 30 days with a mean 10.5 ± 7.5 days/patient. At follow-up, 9 to 60 months mean 34, all patients were symptom-free. NYHA class 2.5 ± 0.8 changed to 1.2 ± 0.4, p < 0.001.

Conclusion

The double-patch sandwich technique (bi-patch closure) offers some advantages and does not result in increased morbidity and mortality. In the case of excising a left ventricular aneurysm, this technique in no way requires eversion of the edges, felt strips, buttressed and multiple sutures, all of which are needed for longitudinal linear closure. Moreover, it does not require purse string sutures, endocardial scar remnant to secure the patch or folding the excluded non-functional tissue, all of which are needed for endoventricular patch repair.

Update on mitral valve surgery

Recently, the outcome for patients with mitral valve disease has significantly improved. This may be due to concomitant advances in many fields. In particular, the development of surgical techniques has contributed to this improvement, and many surgical techniques and topics are introduced in this article. After the evaluation of results in mitral valve surgery and exploration of the relationship between the mitral valve and the mitral subvalvular apparatus, it is currently accepted that mitral valve repair is superior to replacement and that replacement with preservation of the mitral subvalvular apparatus is preferable to replacement alone. Another current topic is mitral repair in dilated cardiomyopathy. Mitral regurgitation is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis because of progressive mitral annular dilatation. Recently, to solve this problem, undersized mitral annuloplasty or cardiomyoplasty has been advocated. In the future, mitral valve surgery may be performed off-pump or by a percutaneous approach. Several groups are investigating the use of new devices and new techniques that avoid cardiopulmonary bypass in experimental studies. In this article, we review current topics and discuss our experiences in mitral valve surgery.

Absent Long-Term Benefit of Patch Versus Linear Reconstruction in Left Ventricular Aneurysm Surgery

BACKGROUND

Endoventricular patch reconstruction of the left ventricle is considered the gold standard in surgery for left ventricular aneurysms, because of improved preservation of ventricular geometry. However, the superiority over conventional linear closure has not been demonstrated, as assessed by the long-term outcome.

METHODS

Two hundred patients (66%) underwent linear closure (group L) and 105 patients (34%) had endoventricular patch reconstruction (group D) using the Dor technique. Linear closure has been performed since 1974 and from 1985 on the Dor technique has been applied as an alternative procedure. Both patient groups differed regarding age, sex distribution, site of infarction, and indication for surgery. Prior to the operation, 71% of the patients were in New York Heart Association (NYHA) class III or IV and mean ejection fraction was 34% +/- 12%. Follow-up extends up to 25 years, with a cumulative total of 2,605 patient years.

RESULTS

Early mortality was 6.5% in group L vs 5.7% in group D (not significant [NS]). Actuarial survival after 10 years was 56 +/- 3.2%, with no difference between groups. Freedom from reoperation after 10 years was 95.6% in group L vs 95.2% in group D (NS). Preoperative risk factors for late mortality were age, left ventricular enddiastolic volume index and concomitant mitral valve surgery. The type of procedure and the date of operation had no influence on mortality. To date, 63% of the survivors are in NYHA class I and II.

CONCLUSIONS

In regard to long-term survival, rate of reoperation, and postoperative NYHA functional class, no benefit could be demonstrated when linear closure was compared with ventricular patch reconstruction for LV aneurysm repair. Hence, the technique of ventricular reconstruction may not be as important as previously thought, and at least for small aneurysms the simple and time sparing technique of linear closure may still be considered.

Atrial Natriuretic Peptide Helps Prevent Late Remodeling After Left Ventricular Aneurysm Repair

BACKGROUND

Left ventricular aneurysm repair (LVR) reduces LV wall stress and improves LV function. However, as we reported previously, the initial improvement of LVR was short-term because of LV remodeling but could be maintained longer with postoperative use of an angiotensin-converting enzyme (ACE) inhibitor. Atrial natriuretic peptide (ANP) has been used to treat patients with heart failure by natriuretic and vasodilatory actions. Recent reports have suggested that ANP inhibits the rennin-angiotensin system. In this study, the effects of ANP after LVR were evaluated.

METHODS AND RESULTS

Rats that had an LV aneurysm 4 weeks after left anterior descending artery ligation underwent LVR by plicating the LV aneurysm and were randomized into 2 groups: LVR+A group was intravenously administrated with 10 microg/h of carperitide, recombinant alpha-hANP, by osmotic-pump for 4 weeks, and the LVR group was given normal saline. Echocardiography revealed better LV remodeling and function in LVR+A group than in LVR group. Four weeks after LVR, left ventricular end diastolic pressure (LVEDP) and Tau were significantly lower in LVR+A group (LVEDP: 10+/-4 in LVR+A group versus 18+/-6 mm Hg in LVR group, Tau: 13+/-2 versus 17+/-2ms). End-systolic elastance (Ees) was higher in LVR+A group (Ees: 0.34+/-0.2 versus 0.19+/-0.11 mm Hg/microL). The levels of myocardial ACE activity in LVR+A group was significantly lower than in LVR group. The mRNA expressions of brain natriuretic peptide and transforming growth factor beta1 inducing fibrosis significantly decreased in LV myocardium in LVR+A group. Histologically, myocardial fibrosis was significantly reduced in LVR+A group.

CONCLUSIONS

Intravenous administration of ANP had beneficial effects on LV remodeling, function, and fibrosis after LVR. ANP could be a useful intravenous infusion drug for postoperative management after LV repair surgery.

Surgery for left ventricular aneurysm: Early and late survival after simple linear repair and endoventricular patch plasty

OBJECTIVE

Simple linear resection and endoventricular patch plasty are alternative techniques to repair postinfarction left ventricular aneurysm. The aim of the study was to compare these 2 methods with regard to early mortality and long-term survival.

METHODS

We retrospectively reviewed 159 patients undergoing operations between 1989 and 2003. The epidemiologic design was of an exposed (simple linear repair, n = 74) versus nonexposed (endoventricular patch plasty, n = 85) cohort with 2 endpoints: early mortality and long-term survival. The crude effect of aneurysm repair technique versus endpoint was estimated by odds ratio, rate ratio, or relative risk and their 95% confidence intervals. Stratification analysis by using the Mantel-Haenszel method was done to quantify confounders and pinpoint effect modifiers. Adjustment for multiconfounders was performed by using logistic regression and Cox regression analysis. Survival curves were analyzed with the Breslow test and the log-rank test.

RESULTS

Early mortality was 8.2% for all patients, 13.5% after linear repair and 3.5% after endoventricular patch plasty. When adjusted for multiconfounders, the risk of early mortality was significantly higher after simple linear repair than after endoventricular patch plasty (odds ratio, 4.4; 95% confidence interval, 1.1-17.8). Mean follow-up was 5.8 +/- 3.8 years (range, 0-14.0 years). Overall 5-year cumulative survival was 78%, 70.1% after linear repair and 91.4% after endoventricular patch plasty. The risk of total mortality was significantly higher after linear repair than after endoventricular patch plasty when controlled for multiconfounders (relative risk, 4.5; 95% confidence interval, 2.0-9.7). Linear repair dominated early in the series and patch plasty dominated later, giving a possible learning-curve bias in favor of patch plasty that could not be adjusted for in the regression analysis.

CONCLUSIONS

Postinfarction left ventricular aneurysm can be repaired with satisfactory early and late results. Surgical risk was lower and long-term survival was higher after endoventricular patch plasty than simple linear repair. Differences in outcome should be interpreted with care because of the retrospective study design and the chronology of the 2 repair methods.

Surgical Repair of Mechanical Complications of Myocardial Infarction

Mechanical complications of acute myocardial infarction are estimated to account for 25,000 fatalities yearly in the United States. The diagnosis necessitates a high degree of clinical suspicion. Once recognized, prompt surgical intervention is necessary because if left untreated the condition frequently causes a fatal outcome. The main determinants of survival are the preoperative hemodynamic status of the patient, the presence of multisystem failure at presentation, and concomitant revascularization during repair of the defect. Because ischemic heart disease remains the leading cause of death in such patients following repair, coronary artery bypass should be considered and, whenever possible, performed in conjunction with repair of the postinfarct mechanical complication.

Repair of left ventricular aneurysm: surgical risk and long-term survival

BACKGROUND

The aim of the study was to identify predictors for survival after repair of postinfarction left ventricular aneurysm.

METHODS

We retrospectively reviewed the records of 149 patients who had an operation for postinfarction left ventricular aneurysm between 1989 and 2001. The following variables were recorded: preoperative clinical, angiographic, and echocardiographic findings and operative procedures. Outcomes were early mortality (<30 days) and long-term survival. Risk factors were pinpointed using t test or Mann-Whitney test, contingency tables, and survival curves. Independent risk factors were identified by logistic regression and Cox regression methods. Mean follow-up was 5.8 years (range, 0 to 13.8 years).

RESULTS

The early mortality (<30 days) rate was 8.7% altogether, and the 5-year cumulative survival rate was 77%. Advanced age, history of ventricular arrhythmia, three-vessel disease, and linear repair technique were independent risk factors for early and total mortality. Poor left ventricular function predicted reduced long-term survival but did not increase surgical risk. Survival was not affected by gender, diabetes, type and severity of symptoms, anterior or posterior aneurysm, revascularization of the left anterior descending artery, or number of distal anastomoses.

CONCLUSIONS

Postinfarction left ventricular aneurysm can be repaired with acceptable surgical risk and long-term survival. Survival is reduced in cases with advanced age, history of ventricular arrhythmia, three-vessel disease, poor left ventricular function, and linear repair of the aneurysm.

Effects of two inhibitors of renin-angiotensin system on attenuation of postoperative remodeling after left ventricular aneurysm repair in rats

We reported that the initial beneficial effects of left ventricular repair (LVR) surgery for LV aneurysm after myocardial infarction (MI) did not persist because of postoperative LV remodeling in a rat model. The renin-angiotensin system (RAS) plays an important role in postinfarction LV remodeling. Inhibition of RAS may be useful to preserve LV function by preventing remodeling. We studied the effects of two inhibitors of RAS in an attempt to improve the operative results of LVR. LV aneurysms were created in rats after ligating the left anterior descending artery. These rats underwent LVR by plicating the LV aneurysm and were treated by three methods: no treatment, treatment with angiotensin-converting enzyme inhibitor (ACE-I) (lisinopril 10 mg/kg per day), and treatment with angiotensin II receptor blocker (ARB) (candesartan 5 mg/kg per day). One week after LVR, echocardiography revealed smaller LV size and better LV motion than before surgery. Four weeks after LVR, LV size returned to the preoperative value in the untreated group, but not as much in the treated groups. Cardiac catheterization revealed lower LV end-diastolic pressure and higher E-max in the treated groups. There was no difference between ACE-I and ARB groups except for systolic blood pressure. LVR decreased LV size and improved systolic function only in the early phase. Adjuvant therapy of ACE-I or ARB-attenuated LV remodeling and maintained LV function at the same level after LVR. This probably indicates that tissue RAS is associated with postoperative remodeling. Concomitant use of RAS inhibitors may make LVR a longer-lasting procedure for LV aneurysm.

Surgical treatment of post infarction left ventricular aneurysms: our experience with double breasting and Dor's repair

BACKGROUND

This is a retrospective study of left ventricle (LV) aneurysm repair done at the Escorts Heart Institute and Research Centre, New Delhi, since October 1988. Two methods of LV aneurysm repair are practiced: double breasting (DB) and Dor's repair. The method varies with location, size, and extent of aneurysm and quality of the fibrotic wall of the aneurysm.

METHODS

Between October 1988 and May 2001, 129 patients underwent LV aneurysm repair using one of the two techniques; 78 patients had Dor's repair while 51 patients had DB repair.

RESULTS

Overall mortality was 2.3% (three patients). One patient died in the DB group, and two patients died in the Dor's repair group. Mean preoperative ejection fraction (EF) after surgery in DB was 31% while in Dor's repair it was 29.2%. EF showed improvement after surgery to 48.5% in DB and 46.6% in Dor's repair. Decrease in end-diastolic volume (EDV) in DB was from 146 to 91.4 cm3/m2, and in Dor's repair it was from 156 cm3/m2 to 88.6 cm3/m2. Decrease in end-systolic volume was from 101 cm3/m2 to 60.2 cm3/m2 in DB and from 109 cm3/m2 to 64.5 cm3/m2 in Dor's group. All of these values showed statistically significant improvement. At six months postoperatively, 83 patients (74.1%) out of 112 patients who were preoperatively in New York Heart Association (NYHA) Functional Classes III and IV improved to class II while 7 patients (6.3%) improved to class I.

CONCLUSION

In our experience Dor's repair is indicated for anteroseptal and apical isolated posterior aneurysm to restore LV volume and geometry while DB is indicated for apical, anterolateral, and lateral aneurysms where septal involvement is less. These two techniques have definite indications and advantages with good results.

A rat model of ischaemic or dilated cardiomyopathy for investigating left ventricular repair surgery

1. The effects of left ventricular repair (LVR) surgery for ischaemic or dilated cardiomyopathy are not fully understood. The development of a proper animal model will help to resolve this issue. 2. The ischaemic cardiomyopathy (ICM) model used was as follows. Twenty-six rats developed ICM with a large akinetic left ventricular (LV) area after ligation of the left anterior descending artery (LAD). Four weeks after surgery, 13 rats underwent LVR by placating the akinetic area (LVR group), while 13 underwent rethoracotomy alone (sham group). 3. The dilated cardiomyopathy (DCM) model is as follows. Six Dahl salt-sensitive (DS) rats were fed an 8% NaCl diet from the age of 9 weeks and developed DCM. These rats had LVR by plicating the LV area between the papillary muscle bases (LVR group), while other rats underwent rethoracotomy alone (sham group). 4. Before LAD ligation in the ICM model or starting the high-salt diet in the DCM model and just before and after LVR or sham surgery, LV dimensions were measured by echocardiography and the heart rate and systolic blood pressure were recorded by the tail-cuff method. 5. In the ICM model, all rats survived the second surgery, after which LV end-diastolic diameter (EDD) decreased, LV fractional shortening (FS) increased (both P < 0.001 vs sham) and heart rate increased (P < 0.05) in the LVR group. 6. In the DCM model, LV EDD decreased and LV FS increased (both P < 0.001) in the LVR group. 7. Both models developed LV dilatation, tolerated LVR and enable reproducible physiological evaluation of the LV. Because the rats survived thereafter, both models may provide a useful tool for various investigations.

Short and long term survival of surgical treatment of left ventricular aneurysms: ten years experience

Although surgical treatment of left ventricular aneurysms has been performed for a long time, it is still a point of debate. In this study, we investigated 159 patients who had undergone surgery for a left ventricular aneurysm in our clinic between 1985 and 1994. Perioperative mortality, long term survival rates, and parameters which probably affect these ratios were evaluated. All of the patients except one were followed by clinical records, mail or phone. Classic linear repair (111 cases), plication (46 cases), and Dor plasty (2 cases) were performed. Revascularisation procedure was also performed in 140 (88%) cases. The average number of distal anastomosis was 2.6. Twenty cases (12.6%) died in the perioperative period. The most important parameter which affected early mortality was the requirement for an intra-aortic balloon pump in the postoperative period. Mean follow-up duration was 47 +/- 35 months. Forty-two late deaths occurred in this period. The overall 5-year survival rate was 71%. Predictors for long term mortality were related to preoperative left ventricular function, presence of congestive heart failure, and poor functional capacity. The type of surgery did not affect short and long term survival. The functional capacity of the survivors was improved. In conclusion, surgical treatment of left ventricular aneurysms with classic linear repair and plication had acceptable short and long term survival rates and improved functional capacity. The most important predictor of survival in either the early or late postoperative period was preoperative left ventricular function.

Repair of postinfarction dyskinetic LV aneurysm with either linear or patch technique

OBJECTIVES

Controversy still exists regarding the optimal surgical technique for postinfarction dyskinetic left ventricular aneurysm (LVA) repair. We compared the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LVA.

PATIENTS AND METHODS

From 1989 to 1998, 95 (16 women, 79 men) consecutive patients were operated on for postinfarction dyskinetic LVA. Thirty-four patients underwent patch remodeling (R) and 61 linear (L) repair. The mean age was 61.1+/-8.5 years. Indications for surgery alone or in combination included angina in 72 patients, dyspnea in 64 and ventricular tachycardia in 41. Thirty-seven patients had a history of congestive heart failure (R 13 (38%), L 24 (39%), NS). The mean ejection fraction (EF) with aneurysm was 0.29+/-0.09 in R vs. 0.35+/-0.10 in L (P<0.04), whereas the mean EF without aneurysm was 0.43+/-0.11 in R vs. 0.46+/-0.08 in L (P=0.3). Seventy-one aneurysms were anterior (R 30 (88%), L 41 (68%), P<0.05). Concomitant coronary artery bypass grafting was performed in 84 patients (R 29 (85%), L 55 (90%), NS). Follow-up ranged from 1 to 12 years (mean 5.6+/-3.4 years, median 6.1 years).

RESULTS

Early mortality was 8% (n=8) (R 4, L 4, NS). Survival at 1, 5 and 10 years was 88, 73, and 44%, respectively. It did not differ significantly between R (1 and 5 year survival 85, 66%) and L (90, 76%, P=0.58). Preoperative risk factors for mortality were history of congestive heart failure (1 and 5 year survival 81 and 57% vs. 90 and 78%, respectively, hazard ratio (HR)=1.95, P<0.05), non-anterior localization of the aneurysm (86 and 49% vs. 86 and 77%, HR=2.06, P<0.05), history of thromboembolic events (57 and 19% vs. 89 and 74%, HR=3.27, P<0.05), and left ventricular EF (HR=0.97 per %, P=0.05). At late follow-up the mean functional class was 1.8+/-0.6 in long-term survivors (preoperative 2.9+/-0.9, P<0.001) with no difference between the groups.

CONCLUSIONS

The technique of repair of postinfarction dyskinetic LVA should be adapted in each patient to the cavity size and extent of the scarring process into the septum and subvalvular mitral apparatus. Applying these considerations to the choice of the technique of repair, both techniques achieved satisfactory results with respect to perioperative mortality, late functional status and survival.

A rat model of ischemic cardiomyopathy for investigating left ventricular volume reduction surgery

OBJECTIVE

The effects of volume reduction surgery (VRS) for ischemic cardiomyopathy are not fully understood. The development of a proper animal model will help to resolve this issue.

METHODS

Study 1 (Noninvasive study): Twenty-six rats developed large akinetic left ventricular (LV) aneurysms or ischemic cardiomyopathy after anterior descending artery ligation (first surgery). Four weeks after the surgery, 13 rats underwent volume reduction surgery (second surgery) (VRS group), while 13 underwent rethoracotomy alone (sham group). Before the first surgery, and before and after the second surgery, the LV dimensions were measured by echocardiography, and the heart rate and systolic blood pressure were recorded by the tail cuff method. Study 2 (Invasive study): In 7 rats undergoing the VRS and 9 undergoing the sham operation, LV pressure was measured with a manometer-tipped catheter, immediately before and after the second surgery.

RESULTS

Study 1: All rats survived the second surgery, after which LV end-diastolic diameter decreased and LV fractional shortening increased (both p < 0.001) in the VRS group. This group also increased heart rate after the second surgery (p < 0.05). Study 2: There were no differences in LV end-systolic or end-diastolic pressure between the two groups before and after the second surgery.

CONCLUSIONS

This model enables reproducible physiological evaluation of the LV after VRS, and since the rats show postoperative survival, it provides a useful tool for various investigations.

Surgical treatments for heart failure

The surgical options for CHF are a part of a larger paradigm shift in management. Viable and effective surgical options other than cardiac transplant and ventricular assist devices clearly exist and are applicable to a large portion of patients with CHF. These surgical therapies are of acceptable risk before decompensated CHF develops. The rapidly evolving therapies for altering LV remodeling, which underlies CHF progression, are an exciting area that may be joined in the future by molecular advances in myoblast transfer and gene therapy. These therapies are the basis of the discipline of CHF surgery within cardiovascular surgery.

Left ventricular aneurysm repair in rats: structural, functional, and molecular consequences

OBJECTIVES

This study examined the effects of aneurysm repair in a rat model of myocardial infarction on functional indices and on the spatiotemporal distribution of cardiac contractile protein and natriuretic peptide messenger RNA.

METHODS

In a rat infarct model, expanded left ventricular aneurysms were plicated 4 weeks after infarction. At 30 weeks, transverse heart sections were taken at 4 levels (apex [level 1] through base [level 4]) and assessed by in situ hybridization histochemistry to determine regional messenger RNA levels of pre-pro-atrial natriuretic peptide, cardiac alpha-actin, skeletal alpha-actin, myosin light chain-2v, and beta-myosin heavy chain.

RESULTS

Rats with plicated left ventricular aneurysms had reduced left ventricular endocardial circumference (19%, P <.005), lower heart weight ratio (31%, P <.05), left ventricular end-diastolic pressures (51%, P <.05), and increased +/-dP/dt (34%-38%, P <.05). Cardiac messenger RNA levels of pre-pro-atrial natriuretic peptide were reduced in the septum (levels 2 and 3), and skeletal alpha-actin levels were reduced in the septum and left ventricular free wall of plicated rats (level 3). beta-Myosin heavy chain levels were markedly reduced in peri-infarct regions of the left ventricular free wall, septum, and right ventricle in plicated rats at level 4, whereas myosin light chain-2v levels were reduced at levels 2 and 4 in the left ventricular free wall and at level 4 in the right ventricle.

CONCLUSIONS

Plication of left ventricular aneurysm after infarction in the rat significantly reduced cardiac hypertrophy, improved cardiac function, and reduced the upregulation of pre-pro-atrial natriuretic peptide and both fetal and adult contractile protein isoforms associated with cardiac hypertrophy.

Outcome of geometric endoventricular repair in impaired left ventricular function

BACKGROUND

Traditionally, repair of left ventricular aneurysms has been limited to patients with large localized ventricular aneurysms. Repair of dyskinetic segments in the setting of poor left ventricular function is still contentious.

METHODS

Forty patients underwent geometric endoventricular repair, a new technique of ventricular aneurysm repair, over a 2-year period. Two groups of patients undergoing coronary artery bypass grafting (CABG) for left ventricular dysfunction in the same time period were reviewed. Group 1 comprised 23 consecutive patients who underwent geometric endo-ventricular repair along with CABGs, whereas group II consisted of 22 patients who underwent CABG alone.

RESULTS

The early mortality was 9.1% in group I (1 cardiac, 1 noncardiac) and 0 in group II (NS). New York Heart Association class was remarkably improved from 3.4 to 1.4 (p < 0.05) in group I and to a lesser extent in group II (3.7+/-0.5 versus 2.3+/-0.5). Diastolic dimension of left ventricle was significantly reduced from 5.6 cm to 4.4 cm (p < 0.05) in group I and virtually unchanged in group II. There was one late death in each of the groups.

CONCLUSIONS

This technique of geometric left ventricular aneurysm repair is useful in patients with dyskinetic segments and may help in reducing cardiac size.

Ventricular aneurysm repair: a new approach

Repair of chronic left ventricular aneurysm or acute rupture of the heart after myocardial infarction is associated with technical difficulties and major morbidity and mortality. We describe a new endoventricular repair for both conditions. The repair consists of externally covering a Duran ring with Dacron and internally lining it with autologous pericardium. The modified ring is then sewn into the neck of the lesion. The technique is rapid, simple, and hemostatic. After repair of the chronic aneurysm, ventricular hemodynamics are improved during both diastole and systole. We have performed this technique in two patients with chronic aneurysm and one with subacute rupture.

Left ventricular aneurysm repair: an assessment of surgical treatment modalities

OBJECTIVE

Different closure techniques (linear vs. circular), as well as the efficacy of revascularization in the left ventricular aneurysm repair, with regard to immediate and mid-term results, were assessed and factors having influence on the early mortality and morbidity and survival were analyzed.

METHOD

Between January 1991 and November 1996, 248 patients underwent surgical repair for postischemic left ventricular aneurysm. A total of 26 of them were female (10.50%). Linear closure was employed in 121 patients (48.8 %) and circular (patch endoaneurysmorraphy) closure in 127 (51.2%). Coronary revascularization was added in 203 (81.9%) cases. Patients were followed for an average follow-up time of 39.3 months.

RESULTS

Early mortality rate was 6% (15 patients). The difference in mortality rate by the repair method was not statistically significant (8.3% in the linear closure group and 3.9% in the circular closure group, P = 0.15). Absence of preoperative angina pectoris (P = 0.029), dyspnea as the presenting symptom, a preoperative left ventricular segmental wall motion scoring of 14 or greater, a cardiopulmonary bypass duration exceeding 2 h (P = 0.004), an aortic clamping time exceeding 1 h (P = 0.026) were associated with early mortality. Concomitant coronary revascularization had no effect on early mortality. However, low cardiac output state was less frequent in patients with concomitant coronary revascularization (P = 0.022). Functional status improved in both groups. Follow-up extending to 81st month revealed no difference in survival between the groups (84% for linear closure group and 92% in circular closure group, including operative mortality, P = 0.12). However, functional status improvement was better in the patients who underwent circular repair (P = 0.0077). Revascularization appeared as having no important influence on both survival and functional status. A preoperative left ventricular segmental wall motion scoring of 14 or greater was associated with a higher incidence of early mortality, low cardiac output syndrome and poor long-term survival.

CONCLUSION

Left ventricular aneurysm repair is an important therapeutic intervention and can be performed with reliable results, regardless of repair method, either linear or circular. Long term results revealed better functional status in circular repair group. Concomitant coronary revascularization reduced the incidence of low cardiac output state. Performance of the unaffected regions of myocardium was found to be an important determinant of both early and late outcome.

Left ventricular aneurysmectomy; comparison between two techniques; early and late results

OBJECTIVE

The aim of the present study was to evaluate early and late results of two different surgical techniques for left ventricular aneurysms repair. The conventional aneurysmectomy and direct closure of the ventricular wall and the endoventricular patch plasty.

METHODS

We retrospectively reviewed 118 patients operated on for postinfarction left ventricular aneurysm from 1981 to 1994. Eighty-seven patients (Group A) were operated upon between 1981 and 1991 with the conventional technique and 31 patients (Group B) between 1992 and 1994 with the endoventricular patch plasty technique. Preoperative clinical, hemodynamic and echocardiographic evaluation with operative procedures and early postoperative results of all patients are reported. We also analyzed results of late clinical and echocardiographic controls of 34 patients of Group A and all patients of Group B after a mean follow-up of 42 and 28 months, respectively.

RESULTS

Mean number of by-pass grafts was 1.9 in Group A and 2.6 in Group B (P = 0.01). The left anterior descending coronary artery was revascularized in 27 patients of Group A (34.6%) and 26 of Group B (89.7%) (P < 0.001); the left internal mammary artery was used in seven patients of Group A (8.9%) and 24 of Group B (82.8%) (P < 0.001). Hospital mortality in Group A was 10.3% (9/87), in Group B there was no hospital mortality (P > 0.05). Thirty-two patients of Group A (36.8%) and 3 of Group B (9.7%) suffered of low cardiac output syndrome (P = 0.01). At late control, improvements observed in NYHA and CCS classes, left ventricular ejection fraction (all P < 0.001 in both groups versus preoperative values) and left ventricular end-diastolic diameter (P > 0.05 in Group A and P < 0.001 in Group B) proved to be statistically higher in patients of Group B.

CONCLUSIONS

Endoventricular patch plasty associated with a complete myocardial revascularization, in particular of the anterior descending coronary, and a larger use of the internal mammary artery, permits, by means of reconstruction of the left ventricular geometry, a better outcome for patients undergoing left ventricular aneurysmectomy.

Repair of left ventricular aneurysm: long-term results of linear repair versus endoaneurysmorrhaphy

BACKGROUND

Recently, endoaneurysomorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques.

METHODS

Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair.

RESULTS

The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 +/- 0.08 versus 0.30 +/- 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 +/- 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 +/- 0.64 versus 0.18 +/- 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair (p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 +/- 0.11 versus 0.27 +/- 0.11; p = 0.90), left ventricular volume (171.6 +/- 59.1 versus 169.9 +/- 54.4 mL; p = 0.94), and sphericity index (0.61 +/- 0.09 versus 0.61 +/- 0.12; p = 1.0).

CONCLUSIONS

Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

Influence of ejection fraction on hospital mortality, morbidity, and costs for CABG patients

BACKGROUND

Preoperative ejection fraction (EF) has been shown to adversely affect postoperative hospital mortality and morbidity for patients undergoing isolated coronary artery bypass grafting.

METHODS

To investigate influence of EF on isolated coronary artery bypass grafting outcomes (overall hospital mortality, hospital cardiac mortality, hospital morbidity, and hospital costs), data were reviewed from 1,354 consecutive patients who underwent isolated coronary artery bypass grafting between January 1, 1990, and April 30, 1992, at a single nonprofit hospital. Overall hospital mortality was 4.06% (cardiac, 2.36%). Hospital morbidity was 14.25% (including mortality). Hospital costs (not charges) averaged $16,673 per patient. To explore the impact of preoperative EF, EF was stratified into regular intervals. Each interval was then compared with regard to hospital mortality, morbidity, and average costs. A new statistical tool, discharge analysis, was developed to analyze the cost data. This was necessary because previous efforts at cost analysis have used tools inappropriate for real world cost data.

RESULTS

The statistical analysis showed that patients with EF of 0.40 or greater had the best outcomes (lowest mortality, morbidity, and cost). Once the EF is 0.40 or greater the EF does not carry further predictive value. At EF less than 0.40, patients with EF less than 0.30 have a poorer outcome than patients with EF of 0.30 to 0.39.

CONCLUSIONS

(1) Ejection fraction is a valid predictor of mortality, morbidity and resource utilization based on statistical analysis. (2) Patients can be broadly grouped as having EF greater than 0.40, less than 0.30, or from 0.30 to 0.39 with regard to clinical and cost outcomes. (3) Postoperative length of stay is not predicted by risk-adjusted EF. (4) A new tool, discharge analysis, is presented to facilitate cost analysis.

Postinfarction ventricular aneurysms

Ventricular aneurysms are circumscribed, thin-walled fibrous, noncontractile outpouchings of the ventricle. The majority are apically located, true aneurysms of the left ventricle (LV) that occur as a consequence of transmural myocardial infarction (MI). The precursor of aneurysm formation appears to be infarct expansion early after acute MI and occurrence generally relates to infarct size. The presence of underlying hypertension and the use of steroids and nonsteroidal antiinflammatory agents may promote aneurysm formation. The clinical sequelae include congestive heart failure (CHF), thromboembolism, angina pectoris, and ventricular tachyarrhythmias. Late rupture is a particular complication of false aneurysms in which the pericardium is the aneurysm wall. The diagnosis may be suspected by the clinical finding of a diffuse, pansystolic apical thrust, persistent ST-segment elevation on the electrocardiogram, and distortion of the cardiac silhouette on chest x-ray. This can be confirmed using echocardiography, radionuclide ventriculography, and cardiac catheterization. The latter has the additional advantage of being able to delineate the coronary anatomy. Management involves prevention, specific therapy for the various clinical manifestations, and surgery. Therapeutic interventions with thrombolytic agents, aspirin, heparin, and beta blockers that are applied early in the evolution of an MI may limit infarction size, thereby reducing the tendency toward infarct expansion and aneurysm formation. Patients with mild CHF can usually be controlled with the standard combination of angiotensin-converting enzyme inhibitors, diuretics, and digoxin. Thromboembolism is best prevented by anticoagulation with warfarin for at least 3 months after the acute MI. The choice of pharmacotherapy for ventricular tachyarrhythmias should be guided by electrophysiologic studies. The treatment of patients with angina pectoris utilizes conventional therapeutic modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe diastolic dysfunction after endoventriculoplasty

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Linear left ventricular aneurysmectomy: modern imaging studies reveal improved morphology and function

It remains uncertain whether left ventricular aneurysmectomy (LVA) improves ventricular function and whether LVA improves or distorts left ventricular contour. We applied the powerful imaging techniques of multiple-gated acquisition scanning, intraoperative transesophageal echocardiography, and magnetic resonance imaging to assess functional and morphologic changes after LVA in 75 consecutive patients undergoing LVA by conventional resection and linear closure. Fifty-two patients (69%) underwent concomitant coronary artery bypass grafting, 25 (33%) had directed endocardial resection, and 4 (5%) had valve replacement. The hospital mortality rate was 6.7% (5/75). Actuarial survival rates were 86%, 80%, and 64% at 1 year, 2 years, and 5 years, respectively. Mean anginal class improved from 3.49 to 1.24 (p < 0.0001). Mean congestive heart failure class improved from 3.04 to 1.70 (p < 0.0001). By multiple-gated acquisition scan (48 patients), mean ejection fraction improved from 0.25 preoperatively to 0.33 postoperatively (p < 0.0001). Intraoperative transesophageal echocardiography (28 patients) revealed no cases of distortion and demonstrated normalization of left ventricular contour in 69% of patients. Mean wall motion score improved from 16.4 to 18.8 (p < 0.001). Mean cross-sectional area of the left ventricle decreased from 18.7 cm2 to 12.8 cm2 (p < 0.006). Magnetic resonance imaging confirmed normalization of left ventricular contour without distortion. We conclude that linear LVA is clinically effective and objectively improves left ventricular morphology and function. On this basis, we have extended application of LVA to include patients with at least moderate-sized aneurysms undergoing coronary artery bypass grafting, despite the absence of traditional indications of arrhythmia, embolism, and frank congestive heart failure.

Functional results of left ventricular reconstruction

From 1988 to 1991, 48 patients with left ventricular aneurysm underwent endoventriculoplasty with a circular patch to preserve the left ventricular geometry. Of these patients, 98% underwent concomitant myocardial revascularization, and in 77% the left anterior descending coronary artery was bypassed. The overall operative mortality rate was 4.1%. The 3-year survival rate was 91%, and 67% of patients had no further cardiac complications. Cardiac performance was assessed postoperatively by ventriculography in 28 patients. The global ejection fraction rose from 0.39 +/- 0.11 to 0.57 +/- 0.14 (p < 0.001); the left ventricular end-diastolic pressure fell from 20 +/- 7.5 mm Hg to 15 +/- 7.8 mm Hg (p < 0.05). Computerized analysis of regional contraction revealed a significant improvement in the anterolateral and apical segments and in the transitional zone. In 61% of the patients, a normal contraction pattern resumed, whereas in the remaining 39%, a residual deformity of the left ventricular chamber was present. The best results were obtained in patients with a preserved proximal septum at echocardiography.

Regional wall motion analysis predicts survival and functional outcome after subendocardial resection in patients with prior anterior myocardial infarction

BACKGROUND

Subendocardial resection is an established surgical technique for the treatment of ventricular tachycardia associated with prior myocardial infarction. Preoperative factors predictive of survival and functional outcome after surgery have not been completely characterized. We hypothesized that a quantitative assessment of regional wall motion would be a sensitive predictor of both survival and functional outcome after subendocardial resection. This was retrospectively tested in a group of 80 patients with prior anterior myocardial infarction who had undergone subendocardial resection for sustained ventricular tachycardia at out institution.

METHODS AND RESULTS

Centerline chord motion analysis was used to derive a wall motion score from the preoperative contrast right anterior oblique ventriculogram. Multivariate analysis revealed wall motion score to be a significant independent predictor of both long-term survival (p < 0.01) and New York Heart Association (NYHA) functional class I or II status at 6 months (p < 0.01) and at 24 months (p < 0.001) after surgery. Patients with a wall motion score of > 16%, compared with patients with a wall motion score of < or = 16%, had a better 5-year actuarial survival (74% versus 45%, p = 0.02) and were more likely to be NYHA class I or II at 6 months (87% versus 58%, p < 0.01) and at 24 months (82% versus 34%, p < 0.0001) after subendocardial resection.

CONCLUSIONS

A wall motion score derived from centerline chord motion analysis is a sensitive predictor of survival and functional outcome after subendocardial resection. Patients with a wall motion score of > 16% have an excellent prognosis after subendocardial resection. In contrast, patients with a wall motion score of < or = 16% have a poorer outcome and should be considered candidates only if other forms of therapy have failed or are unavailable.