Left ventricular aneurysm repair with myocardial revascularization: an analysis of 246 consecutive patients over 15 years

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.

Establishment of a chronic left ventricular aneurysm model in rabbit

OBJECTIVES

To establish a cost-effective and reproducible procedure for induction of chronic left ventricular aneurysm (LVA) in rabbits.

METHODS

Acute myocardial infarction (AMI) was induced in 35 rabbits via concomitant ligation of the left anterior descending (LAD) coronary artery and the circumflex (Cx) branch at the middle portion. Development of AMI was confirmed by ST segment elevation and akinesis of the occluded area. Echocardiography, pathological evaluation, and agar intra-chamber casting were utilized to validate the formation of LVA four weeks after the surgery. Left ventricular end systolic pressure (LVESP) and diastolic pressure (LVEDP) were measured before, immediately after and four weeks after ligation. Dimensions of the ventricular chamber, thickness of the interventricular septum (IVS) and the left ventricular posterior wall (LVPW) left ventricular end diastolic volume (LVEDV), systolic volume (LVESV), and ejection fraction (EF) were recorded by echocardiogram.

RESULTS

Thirty one (88.6%) rabbits survived myocardial infarction and 26 of them developed aneurysm (83.9%). The mean area of aneurysm was 33.4% ± 2.4% of the left ventricle. LVEF markedly decreased after LVA formation, whereas LVEDV, LVESV and the thickness of IVS as well as the dimension of ventricular chamber from apex to mitral valve annulus significantly increased. LVESP immediately dropped after ligation and recovered to a small extent after LVA formation. LVEDP progressively increased after ligation till LVA formation. Areas in the LV that underwent fibrosis included the apex, anterior wall and lateral wall but not IVS. Agar intra-chamber cast showed that the bulging of LV wall was prominent in the area of aneurysm.

CONCLUSIONS

Ligation of LAD and Cx at the middle portion could induce development of LVA at a mean area ratio of 33.4% ± 2.4% which involves the apex, anterior wall and lateral wall of the left ventricle.

Early results after surgical treatment of left ventricular aneurysm

Background

Left ventricular aneurysm (LVA) is a serious complication of myocardial infarction and reduces the chances of survival. Controversy still exists regarding the optimal surgical technique for LVA repair. We analyze the efficacy of two techniques, linear vs. endoventricular circular patch plasty, for repair of LVA and the efficacy of surgical ventricular restoration (SVR) on beating heart.

Methods

This study included 62 patients who underwent SVR from 1086 consecutive patients were subjected to coronary artery bypass grafting (CABG) between 2000 and 2009. All selected patients were divided either into group liner or patch according to the choice of the repair technique depended on factors such as localization, size and dimension of the scar. The patients also were divided either into group beating heart or cardioplegia. The pre-, intra- and postoperative relevant data of all selected patients were analyzed.

Results

The mortality was not significantly different between linear and patch repair groups, also the actuarial survival rates within 24 months (p= 0.529). Postoperative echocardiographic findings showed significant improvements in left ventricular function in both groups. The beating heart technique reduced postoperative peak release by 27% for Cardiac troponin I (cTnI) compared with the cardioplegia group (0.46 ± 0.06 ng/mL versus 0.63 ± 0.09 ng/mL, p= 0.004), and increased the perioperative survival by 9% (97.2% versus 88.5%), but the actuarial survival rates were not significantly different between the groups from 2 to 24 months (p= 0.151).

Conclusions

Both techniques (linear and patch) achieved good results with respect to mortality, functional status and survival. The choice of surgical technique should be adapted in each patient. The beating heart technique may to some extent relieve myocardial injury in patients undergoing SVR.

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.

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 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.

Adult cardiac surgery during the first 50 years of the Southern Thoracic Surgical Association

This is a review of some of the outstanding adult cardiac surgical papers presented during the first 50 years of the Southern Thoracic Surgical Association to commemorate the 50th Anniversary meeting. Since the founding of the Southern Thoracic Surgical Association in 1954 there have been a total 512 adult cardiac surgery and great vessels papers presented, 138 from 1954 to 1970, 157 from 1971 to 1986, and 217 from 1987 to 2002. Since 1964 most of these papers have been published in The Annals of Thoracic Surgery. Forty-three papers were reviewed, the first having been presented in 1956 and the last in 2002. Not all of the papers could be located but the vast majority were retrievable and reviewed. This paper presents a broad spectrum of adult cardiac surgery beginning with early pump technology, early myocardial revascularization including the Vineberg procedure followed by coronary bypass as we know it today, valvular surgery, including several papers on aortic valve homograft and autograft procedures, ventricular aneurysms, aortic aneurysms and aortic dissections. Evaluations of various valve prostheses, cardiac transplantation, mitral valve reconstruction, quality assurance in cardiac surgery, neurobehavioral outcome after cardiac surgery, endocarditis and off-pump coronary bypass surgery were reviewed. We hope that this article is representative of the broad spectrum of issues that have characterized the specialty of cardiothoracic surgery over the second half of the 20th century and the beginning of the 21st century.

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.

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.

Late hemodynamic results after left ventricular patch repair associated with coronary grafting in patients with postinfarction akinetic or dyskinetic aneurysm of the left ventricle

This study reports hemodynamic, electrophysiologic, and clinical results in 171 patients (157 men and 14 women, mean age 57 +/- 8 years) 1 year after endoventricular circular patch repair and coronary grafting for postinfarction left ventricular dyskinetic or akinetic aneurysm. All patients had hemodynamic and electrophysiologic study before the operation and early and 1 year after the operation. The vast majority of aneurysms were anterior (n = 166), with a mean delay from infarction of 43 +/- 50 months. Fifty-two percent of patients were in New York Heart Association class III or IV, and preoperative ejection fraction was less than 40% in the majority of them (75%). Preoperative clinical ventricular tachycardia was present in 25 patients and was inducible in 59 patients. All patients had endoventricular circular patch repair with a synthetic (n = 99) or autologous patch (n = 72); 96% had associated coronary grafting with a mean number of bypass grafts of 1.9 +/- 0.9. Results at 1 year demonstrated a significant increase in ejection fraction (from 36% +/- 13% to 46% +/- 12% (p < 0.0001) and a significant reduction in ventricular volumes (end-diastolic volume index from 116 +/- 5 to 94 +/- 29 ml/m2 and end-systolic volume index from 77 +/- 45 to 53 +/- 25 ml/m2, p < 0.0001). New York Heart Association functional classification was significantly improved (2.6 +/- 0.9 vs 1.4 +/- 0.6, p < 0.0001) and ventricular tachycardias were almost suppressed (no documented clinical ventricular tachycardias and 8% incidence of inducible ventricular tachycardias after 1 year, chi 2 < 0.001). Patients who benefit most from the operation are those with more severe preoperative left ventricular dysfunction (i.e., ejection fraction < 30%), more frequent ventricular arrhythmias, and larger ventricular volumes. At regression analysis, critical disease of the right coronary artery was the only independent predictor of unsatisfactory pump improvement (as evaluated by postoperative increase of ejection fraction < 10 absolute points). In conclusion, in our large series of patients operated on by one surgical team between 1988 and 1993, who were studied hemodynamically both before and after the operation, endoventricular circular patch repair of left ventricular aneurysm associated with coronary grafting definitely improves left ventricular pump function and clinical status 1 year after the operation.

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.

Technical advances in the treatment of left ventricular aneurysm

The resulting abnormal geometry after surgical treatment of left ventricular aneurysm has concerned a number of surgeons since the first successful repair in 1958, but little attention was placed on the altered geometry until attempts were made to effect a more physiologic aneurysmorrhaphy in 1973. Substantial attention was focused on a concept of geometric reconstruction from within the left ventricle in 1985. A prosthetic patch was employed with the concept to redirect normal muscle bundles to their original orientation and position. Further refinements include use of improved materials for the repair, preservation and bypass of the left anterior descending coronary artery, ablation of ventricular arrhythmias when indicated, and the absence of prosthetic material used in contact with the pericardial surface. Our experience with repair of 61 left ventricular aneurysms at West Jefferson Medical Center over a 4 1/2-year period with a 3.3% mortality rate has prompted a change from the standard linear repair to routine use of a modified endoventricular repair. Currently, the low surgical risk due to advances in left ventricular aneurysmorrhaphy combined with the knowledge that contractile areas will progressively deteriorate in ventricles stressed by poor hemodynamics and with data showing improved left ventricular function postoperatively have led to more liberal recommendations for early left ventricular aneurysm repair.

Heterotopic heart transplantation and recipient heart operation in ischemic heart disease

The role of heterotopic heart transplantation in coronary heart disease has not been defined. Between 1983 and 1988, 28 patients with end-stage ischemic heart disease were managed by heterotopic heart transplantation and adjunctive operation on the recipient heart: coronary artery bypass grafts and aneurysmectomy, 20; coronary artery bypass grafts, 5; and aneurysmectomy, 3. Indications were feasibility of operative procedures to the recipient heart and small donor size (61% of the donors were less than 15 years). The 1-year and 5-year actuarial survival was 79% and 63%. Of the 22 patients who survived to 2-year follow-up, all of whom had been severely limited (New York Heart Association grade III/IV) preoperatively, 20 were in grades I or II at 2-year follow-up (p less than 0.001). In 14 of 22 patients (64%), the recipient heart augmented the donor cardiac output substantially, and in 4 the recipient heart supported the patient when the donor heart failed to eject. In conclusion, this series demonstrates the efficacy of heterotopic transplantation combined with operation to the recipient heart in the management of patients with end-stage ischemic heart disease.

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

A review of 336 consecutive patients who underwent repair of left ventricular aneurysm from 1978 to 1989 disclosed that partial resection of the aneurysm and conventional closure of the ventriculotomy was performed in 281 patients, inverted T closure in 17, and endocardial patch in 38. These two latter techniques were developed in an attempt to restore normal left ventricular geometry. The operative mortality was 6.8% (23 patients). A stepwise logistic regression analysis of various preopeative clinical, hemodynamic, and angiographic variables revealed that left ventricular ejection fraction of 0.20 or less, age greater than 60 years, previous myocardial revascularization, lack of angina, and New York Heart Association functional class IV were independent predictors of operative mortality. The technique of repair was not a predictor of outcome, but when patients with poor left ventricular function were analyzed separately, the operative mortality was reduced from 12.5% to 6.5% when newer techniques were employed. Patients were followed up during a mean of 6.3 years. There have been 51 late deaths, 45 cardiac. Cox regression analysis indicated that poor left ventricular function and left main coronary artery stenosis were the only two predictors of late mortality. The actuarial survival at 10 years was 63% +/- 4%. Most patients (88%) are in New York Heart Association class I or II. These data indicate excellent long-term results after repair of left ventricular aneurysm. Newer techniques of repair are valuable in patients with poor left ventricular function.

Surgical treatment of left ventricular aneurysm. Analysis of risk factors, morbidity and mortality in 205 cases

Left ventricular aneurysm was surgically treated in 205 patients during the decade 1975-1984. The patients had had one to five myocardial infarctions, the latest days to years (mean 32 months) preoperatively and 92% were in NYHA functional class III or IV. The main indications for surgery were angina (47%), congestive heart failure (38%) and arrhythmia (15%). The 176 anterior, 23 posterior and six combined aneurysms were treated with resection (130 cases) or plication (75). The early mortality was 5%. Univariate analysis identified arrhythmia, concomitant valve replacement and need for intra-aortic balloon pumping (IABP) as significant risk factors, and multivariate analysis revealed the indication for surgery and need for IABP as the only independent predictors of total mortality. The survival rates 5 and 10 years postoperatively were respectively, 74% and 60%. At follow-up after 1/2-10 years, almost 90% of the surviving patients had improved functional status. Left ventricular aneurysm thus can be surgically treated with low mortality rate and good functional result.