High incidence of sudden death late after anterior LV-aneurysm repair

Coronary Sparing Aneurysmectomy

Repairing left ventricular aneurysms that form after myocardial infarction may be challenging, especially if located close to the important native coronary arteries. Here, we describe a rare case of anterolateral aneurysm of the basal LV wall and a safe, efficient approach for a patch plasty sparing the native left anterior descending.

Idiopathic right ventricular pseudoaneurysm presenting with ventricular tachycardia: a case report

Right ventricular (RV) pseudoaneurysm is very rare and is seen after penetrating chest trauma, cardiac surgery, infective endocarditis, myocardial infarction, syphilis, endomyocardial biopsy, lead extraction. Idiopathic right ventricular pseudoaneurysm is even rarer. They have varied presentations depending on the etiology. Diagnosis is usually made by echocardiography. We present a case of 21-year-old male who presented to us with palpitations for 2 days and one episode of syncope and was diagnosed with monomorphic ventricular tachycardia (VT) and he was managed with electrical cardioversion during one of the episodes. Echocardiogram and CMR showed a larger right ventricular pseudoaneurysm at apex. Surgical excision was done uneventfully. The patient had no further VT episodes post-surgery. This case highlights the approach to diagnosis and management of RV pseudoaneurysm.

Left ventricular aneurysmectomy in a young female with pseudoaneurysm of unknown etiology

A left ventricular pseudoaneurysm is formed when there is free wall rupture of the myocardial wall with discontinuity and roof covered by pericardium mural thrombus or fibrous tissue without any myocardium. A left ventricular pseudoaneurysm is a rare and life-threatening event. We report a young 22-year-old female with unknown etiology of a pseudoaneurysm, who was previously managed as a psychiatric case and for musculoskeletal pain. On subsequent investigation and confirmation with cardiac magnetic resonance imaging, aneurysmectomy was done. This is a rare case in a young 22-year-old woman with a ventricular pseudoaneurysm of unknown etiology. Considering the high risk for rupture of a ventricular pseudoaneurysm, surgical resection was mandatory with no complications intra- and post-procedure.

Impact of surgical ventricular restoration on early and long-term outcomes of patients with left ventricular aneurysm: A single-center experience

Left ventricular aneurysm (LVA) is a common complication of myocardial infarction. However, the optimal treatment for LVA remains controversial.In this retrospective study, we analyzed the early and long-term clinical consequences of surgical ventricular restoration on 102 patients who had undergone repair between January, 2005 and January, 2015. The LVA repair approaches comprised of patch plasty (n = 28), linear repair (n = 40), and plication repair (n = 34).Patient demographics were 60.8% male, and the mean age was 60.5 ± 7.2 years. The in-hospital mortality rate was 7.8% (8/102), including 6 patients who died from low cardiac output and 2 from multiorgan failure. During the early postoperative period, left ventricular sizes significantly decreased in the patch plasty and linear repair groups compared with the plication group. In addition, all 3 repair techniques greatly ameliorated left ventricular ejection fraction (P < .05), and there was no significant difference in survival rate between groups (P = .25).Surgical ventricular restoration (linear repair, plication repair, and patch plasty) obtained equivalently appreciable outcomes for cardiac function improvement, perioperative mortality, and survival. Selection of a surgical technique for LVA patients should be optimized to individual patient conditions including the morphological characteristics of the aneurysm and ischemic scar.

Aneurysm-related ischemic ventricular tachycardia: safety and efficacy of catheter ablation

Left ventricular aneurysm (LVA) postmyocardial infarction (MI) might be an arrhythmogenic substrate. We examined the safety and efficacy of catheter ablation of LVA-related ventricular tachycardia (VT).Thirty-three consecutive patients who underwent primary catheter ablation of ischemic VT were divided into LVA group (11 patients, mean age 61.9 years, 10 men) and none LVA group. Acute procedural outcomes, complications, and long-term outcomes were assessed.In LVA group, average number of induced VTs were 3.2 ± 2.6 (range 1-7), clinical VTs were located in the ventricular septum scar zone in 4 (36.4%) patients, acute success was achieved in 7 (63.6%) patients, partial success in 3 (27.3%) and failure in 1 patient, while none LVA group showing a statistically similar distribution of acute procedural outcomes (P = 0.52). There were no major or life-threatening complications. VT-free survival rate at median 19 (1-44) months follow-up was numerically but not significantly lower in LVA versus none LVA group (48.5% vs 62.8%, log-rank P = 0.40).Catheter ablation of ischemic VT in the presence of LVA appears feasible and effective, with about one-third of cases having septal ablation targets. Further studies are warranted.

Epicardial unipolar radiofrequency ablation for left ventricular aneurysm related ventricular arrhythmia

We report a case of a 62-year-old Chinese man with typical triple-vessel lesions and apical left ventricular aneurysm accompanied with ventricular tachycardia. Off-pump coronary artery bypass (OPCAB) grafting was performed in combination with epicardial unipolar radiofrequency ablation and linear closure of left ventricular aneurysm. The patient recovered well without postoperative complications. Holter monitoring showed no recurrence of the ventricular arrhythmia and the attack frequency of arrhythmia decreased significantly. The patient has been angina-free for 25 months since the operation and shows increasing exercise tolerance. Thus, left ventricular aneurysm plication combined with epicardial unipolar radiofrequency ablation during OPCAB may be beneficial for patients with ventricular aneurysm and preoperative malignant ventricular arrhythmia.

The renewed concept of the Batista operation for ischemic cardiomyopathy: maximum ventricular reduction

OBJECTIVES

The reconstruction of the left ventricle (LV) is effective in the treatment of ischemic cardiomyopathy with large akinetic or dyskinetic areas. However, late survival outcomes are related to the remnant left ventricular cavity size, thus eliminating intracavitary patch placement provides additional LV reduction. The aim of this study was to analyze the results with left ventricular reconstruction surgery using the concept of maximum ventricular reduction, with systematic patch abolition.

METHODS

Seventy-six consecutive patients with ischemic heart disease (age 30-78 years, mean 57.6 ± 10.1), evolving in functional class III and IV underwent surgical ventricular reconstruction with no use of intracavitary patches or Teflon strips for closing the left ventriculotomy.

RESULTS

The left ventricular end-systolic diameter decreased from 52.3 ± 5.4 in the preoperative period to 45.2 ± 6.9 mm in the postoperative period. LV ejection fraction increased from 34.2% ± 10.4% to 45.5% ± 9.4%. Associated CABG was performed in 75/76 patients with a mean of 2.4 grafts per patient. The 30-day mortality was 3/76 (3.9%). At an average follow up of 39 months, the majority of the patients (91.4%) remain in functional class I and II.

CONCLUSION

The concept of maximizing LV reduction with systematic patchless reconstruction is feasible, safe and effective, the early and late outcomes comparing favorably to previous series reported in the medical literature. Additionally, the concept meets the contemporary pathophysiologic basis of heart failure.

Is the coexistence of sustained ST-segment elevation and abnormal Q waves a risk factor for electrical storm in implanted cardioverter defibrillator patients with structural heart diseases?

AIM

The aim of this study was to determine whether or not the coexistence of sustained ST-segment elevation and abnormal Q waves (STe-Q) could be a risk factor for electrical storm (ES) in implanted cardioverter defibrillator (ICD) patients with structural heart diseases.

METHODS AND RESULTS

In all, 156 consecutive patients received ICD therapy for secondary prevention of sudden cardiac death and/or sustained ventricular tachyarrhythmias were included. Electrical storm was defined as ≥3 separate episodes of ventricular tachycardia (VT) and/or ventricular fibrillation (VF) terminated by ICD therapies within 24 h. During a mean follow-up of 1825 ± 1188 days, 42 (26.9%) patients experienced ES, of whom 12 had coronary artery disease, 15 had idiopathic dilated cardiomyopathy, 6 had hypertrophic cardiomyopathy, 4 had arrhythmogenic right ventricular cardiomyopathy, 4 had cardiac sarcoidosis, and 1 had valvular heart disease. Sustained ST-segment elevation and abnormal Q waves in ≥2 leads on the 12-lead electrocardiography was observed in 33 (21%) patients. On the Kaplan-Meier analysis, patients with STe-Q had a markedly higher risk of ES than those without STe-Q (P< 0.0001). The multivariate Cox proportional hazards regression model indicated that STe-Q and left ventricular ejection fraction (LVEF) (<30%) were independent risk factors associated with the recurrence of VT/VF (STe-Q: HR 1.962, 95% CI 1.24-3.12, P= 0.004; LVEF: HR 1.860, 95% CI 1.20-2.89, P= 0.006), and STe-Q was an independent risk factor associated with ES (HR 4.955, 95% CI 2.69-9.13, P< 0.0001).

CONCLUSION

Sustained ST-segment elevation and abnormal Q waves could be a risk factor of not only recurrent VT/VF but also ES in patients with structural heart diseases.

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.

Left ventricular circumferential plication: novel off-pump ventricular restoration in swine model

We hypothesized that left ventricular (LV) and subvalvular geometries could be restored in a less invasive manner by circumferential plication without a ventriculotomy or a cardiopulmonary bypass (CPB). Continuous sutures were placed circumferentially on the epicardial surface of the LV wall without using a CPB in six healthy pigs. Coronary artery occlusion was precluded by placing the sutures underneath the peripheral coronary artery. After the circumferential sutures were plicated to 75% of the original length, hemodynamics were recorded and LV geometries and function were measured. All animals survived after plication without arrhythmia or hemodynamic deterioration. Angiogram findings demonstrated that plication reduced the LV end-diastolic volume (LVEDV) (72+/-10 vs. 58+/-12 ml, P<0.05), and sphericity (0.62+/-0.04 vs. 0.58+/-0.03, P<0.05). Also, three-dimensional echocardiography (3D-echo) showed that plication reduced the papillary muscle distance (27+/-3 vs. 18+/-2 mm, P<0.05). We demonstrated the effectiveness of off-pump circumferential plication, which reduced LV volume and altered subvalvular geometry without causing hemodynamic deterioration in an acute animal model. This pilot study suggests that our novel technique is feasible and should next be tested in a chronic model with a dilated failing heart, before clinical application is warranted.

Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control

OBJECTIVES

Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR).

DESIGN

The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers.

RESULTS

Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia.

CONCLUSIONS

Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: The Karolinska approach

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Endoaneurysmorrhaphy and cryoablation for postinfarction left ventricular aneurysm with ventricular tachycardia

BACKGROUND

Early reperfusion in the acute phase of myocardial infarction and better medical treatment of consequent heart failure and tachyarrhythmia have decreased the incidence of massive myocardial infarction, left ventricular (LV) aneurysm and also postinfarction-sustained ventricular tachycardia (VT). However, for a number of patients, surgical ablation combined with aneurysm resection and myocardial revascularization remains a possible curative procedure. In this study, the efficacy of endoaneurysmorrhaphy and cryoablation was evaluated in patients with postinfarction LV aneurysm with VT.

METHODS

The medical records of 9 patients who underwent LV endoaneurysmorrhaphy and cryoablation for VT at Taipei Veterans General Hospital between January 1995 and August 2005 were reviewed retrospectively.

RESULTS

There were 8 men and 1 woman, with a mean age of 69.7 years (range, 52-77 years). Preoperative VT and LV aneurysm were found in all patients, who underwent extensive cryoablation at the transitional zone of scar and viable tissue without intraoperative mapping and LV remodeling with prosthetic patch. Associated procedure included coronary artery bypass grafting in 8 patients. During follow-up, no surgical or in hospital mortality were noted. There was 1 late sudden death at home 1.7 months after the operation. No recurrent VT was detected, and all patients showed improvement in New York Heart Association functional class (mean, 2.33 vs.1.67; p=0.025) and LV ejection fraction (mean, 26.3% vs.34.1%; p=0.021).

CONCLUSION

In patients suffering from postinfarction LV aneurysm complicated with VT, combining cryoablation and endoaneurysmorrhaphy offers good arrhythmia control and clinical outcome.

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Surgery for Ventricular Tachycardia in Patients Undergoing Left Ventricular Reconstruction by the Dor Procedure

BACKGROUND

Surgical ventricular restoration (the Dor procedure) is an option in patients with coronary artery disease and postinfarction left ventricular aneurysm. The procedure can be extended to treat ventricular tachycardia (VT). The aim of this study was to evaluate the Dor procedure including VT surgery in our institution.

METHODS

From July 1997 to December 2003, 53 consecutive patients with left ventricular aneurysm and VT underwent surgical ventricular restoration including nonguided endocardiectomy and cryoablation. Twenty-four patients had at least one preoperative episode of spontaneous VT, of which 8 were survivors of sudden cardiac death. Twenty-nine patients had inducible-only VT. In 45 patients, who underwent preoperative programmed stimulation, sustained uniform VT could be initiated. Arrhythmia control was evaluated by programmed stimulation or analysis of events registered by implanted defibrillators and by review of patient's records.

RESULTS

Early mortality was 2 of 53 (3.8%). Mean follow-up was 3.7 years. At 1, 3, and 5 years overall actuarial survival was 94%, 80%, and 59%, respectively. Surgical success rate in patients with preoperative spontaneous VT was 91%. Inducible VT was found in 5 of 35 patients who underwent postoperative programmed stimulation. There was no arrhythmia-related late death and there was no loss to follow-up.

CONCLUSIONS

The Dor procedure including VT surgery is an effective treatment for postinfarction left ventricular aneurysm and VT and eliminates the need for an implantable defibrillator in most patients. Early and long-term results are good in terms of survival and arrhythmia control.

Residual high incidence of ventricular arrhythmias after left ventricular reconstructive surgery

OBJECTIVE

Left ventricular reconstruction is performed in patients with ischemic cardiomyopathy and akinetic or dyskinetic left ventricular regions. These patients may remain at risk for malignant ventricular arrhythmias and hence may benefit from prophylactic implantable cardioverter-defibrillators. Specific guidelines for electrophysiologic testing and implantable cardioverter-defibrillator implantation in patients undergoing left ventricular reconstruction are lacking. We aimed to assess the residual risk and timing of ventricular arrhythmias after left ventricular reconstruction to determine whether electrophysiologic risk stratification or implantable cardioverter-defibrillator implantation can be safely deferred.

METHODS

Data were prospectively gathered on 217 consecutive patients with left ventricular ejection fractions less than 40% undergoing left ventricular reconstruction at our institution from 1997 to 2002. Patients were divided into 3 groups: group 1, implantable cardioverter-defibrillator present before surgery; group 2, implantable cardioverter-defibrillator implanted early after surgery; and group 3, no implantable cardioverter-defibrillator implanted. End points were all-cause mortality (censored for cardiac transplantation) and appropriate implantable cardioverter-defibrillator therapies.

RESULTS

Of 217 patients (mean age, 61 +/- 10 years [mean +/- SD]), survival after a median follow-up of 381 days was 90%. Electrophysiologic studies successfully identified patients at low risk. Appropriate implantable cardioverter-defibrillator therapies occurred in 20% of group 1 and 12% of group 2. The median time to the first implantable cardioverter-defibrillator therapy from the time of left ventricular reconstruction was 43 days, and most first therapies (67%) occurred within the first 63 days.

CONCLUSIONS

The early event rates (occurring in the first 90 days after left ventricular reconstruction) support the use of predischarge electrophysiologic studies, implantation of implantable cardioverter-defibrillators before discharge from the hospital, or both.