Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques

Association of monocyte to HDL cholesterol ratio and a composite risk score with left ventricular aneurysm formation in patients with acute ST-segment elevation myocardial infarction

BACKGROUND

Left ventricular aneurysm (LVA) is an important complication of acute myocardial infarction. This study aimed to investigate the potential predictive value of the monocyte count to high-density lipoprotein cholesterol ratio (MHR) and a composite risk score in determining the formation of LVA in patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention.

METHODS

We recruited 1005 consecutive patients with STEMI. Multivariable logistic regression analysis was conducted identify the independent risk factors for LVA formation. Predictive power of MHR and composite risk score for LVA formation were assessed using receiver operating characteristic curve analysis.

RESULTS

The MHR was significantly higher among patients with LVA compared to those without LVA [6.6 (3.8-10.8) vs. 4.6 (3.3-6.3), P < 0.001]. Univariable logistic regression analysis revealed that MHR (OR = 3.866, 95% CI = 2.677-5.582, P < 0.001) was associated with the risk of LVA formation. The predictive value of MHR remained significant even after multivariate logistic regression analysis [odds ratio (OR) = 4.801, 95% confidence interval (CI) = 2.672-8.629, P < 0.001]. The discriminant power of MHR for LVA is 0.712, which is superior to both monocyte (C statistic = 0.553) and high-density lipoprotein cholesterol (C statistic = 0.654). The composite risk score including MHR, gender, LVEF, hemoglobin, lymphocyte and left anterior descending artery as the culprit vessel could significantly increase the predictive ability (C statistic = 0.920).

CONCLUSION

A higher MHR could effectively identify individuals at high risk of LVA formation, especially when combined with gender, LVEF, hemoglobin, lymphocyte and left anterior descending artery as the culprit vessel.

IL6/adiponectin/HMGB1 feedback loop mediates adipocyte and macrophage crosstalk and M2 polarization after myocardial infarction

Background

Differences in border zone contribute to different outcomes post-infarction, such as left ventricular aneurysm (LVA) and myocardial infarction (MI). LVA usually forms within 24 h of the onset of MI and may cause heart rupture; however, LVA surgery is best performed 3 months after MI. Few studies have investigated the LVA model, the differences in border zones between LVA and MI, and the mechanism in the border zone.

Methods

The LVA, MI, and SHAM mouse models were used. Echocardiography, Masson's trichrome staining, and immunofluorescence staining were performed, and RNA sequencing of the border zone was conducted. The adipocyte-conditioned medium-treated hypoxic macrophage cell line and LVA and MI mouse models were employed to determine the effects of the hub gene, adiponectin (ADPN), on macrophages. Quantitative polymerase chain reaction (qPCR), Western blot analysis, transmission electron microscopy, and chromatin immunoprecipitation (ChIP) assays were conducted to elucidate the mechanism in the border zone. Human subepicardial adipose tissue and blood samples were collected to validate the effects of ADPN.

Results

A novel, simple, consistent, and low-cost LVA mouse model was constructed. LVA caused a greater reduction in contractile functions than MI owing to reduced wall thickness and edema in the border zone. ADPN impeded cardiac edema and promoted lymphangiogenesis by increasing macrophage infiltration post-infarction. Adipocyte-derived ADPN promoted M2 polarization and sustained mitochondrial quality via the ADPN/AdipoR2/HMGB1 axis. Mechanistically, ADPN impeded macrophage HMGB1 inflammation and decreased interleukin-6 (IL6) and HMGB1 secretion. The secretion of IL6 and HMGB1 increased ADPN expression via STAT3 and the co-transcription factor, YAP, in adipocytes. Based on ChIP and Dual-Glo luciferase experiments, STAT3 promoted ADPN transcription by binding to its promoter in adipocytes. In vivo, ADPN promoted lymphangiogenesis and decreased myocardial injury after MI. These phenotypes were rescued by macrophage depletion or HMGB1 knockdown in macrophages. Supplying adipocytes overexpressing STAT3 decreased collagen disposition, increased lymphangiogenesis, and impaired myocardial injury. However, these effects were rescued after HMGB1 knockdown in macrophages. Overall, the IL6/ADPN/HMGB1 axis was validated using human subepicardial tissue and blood samples. This axis could serve as an independent factor in overweight MI patients who need coronary artery bypass grafting (CABG) treatment.

Conclusion

The IL6/ADPN/HMGB1 loop between adipocytes and macrophages in the border zone contributes to different clinical outcomes post-infarction. Thus, targeting the IL6/ADPN/HMGB1 loop may be a novel therapeutic approach for cardiac lymphatic regulation and reduction of cell senescence post-infarction.

Axin2 depletion in macrophages alleviated senescence and increased immune response after myocardial infarction

OBJECTIVE AND DESIGN

This study aimed to investigate Axin2 effects on myocardial infarction (MI) using a macrophage Axin2 conditional knockout (cKO) mouse model, RAW264.7 cell line, and human subepicardial tissues from patients with coronary artery bypass graft (CABG).

MATERIAL OR SUBJECTS

Axin2 cKO mice showed decreased cardiac function, reduced edema, increased lymphangiogenesis, and improved repair in MI Few studies border zones. Hypoxic macrophages with Axin2 depletion exhibited decreased senescence, elevated IL6 expression, and increased LYVE1 transcription. Senescent macrophages decreased in patients with CABG and low Axin2 expression.

TREATMENT

Treatment options included in this study were MI induction in Axin2 cKO mice, in vitro experiments with RAW264.7 cells, and analysis of human subepicardial tissues.

METHODS

Assays included MI induction, in vitro experiments, and tissue analysis with statistical tests applied.

RESULTS

Axin2 cKO improved cardiac function, reduced edema, enhanced lymphangiogenesis, and decreased senescence. Hypoxic macrophages with Axin2 depletion showed reduced senescence, increased IL6 expression, and elevated LYVE1 transcription. Senescent macrophages decreased in patients with CABG and low Axin2 expression.

CONCLUSION

Targeting Axin2 emerges as a novel therapeutic strategy for regulating cardiac lymphatics and mitigating cell senescence post-MI, evidenced by improved outcomes in Axin2-deficient conditions.

Myocardial Infarction Presenting as Both Left Ventricular Aneurysm and Ventricular Septal Defect

Acute myocardial infarction can result in various mechanical complications, although they have become rare with the advent of reperfusion therapies. Among these complications, ventricular septal rupture (VSR) and left ventricular aneurysm (LVA) are infrequent but life-threatening conditions associated with high morbidity and mortality. We present a rare case of a 67-year-old male with acute myocardial infarction who developed concomitant apical LVA and ventricular septal rupture.

LEARNING POINTS

Mechanical complications of myocardial infarction, such as a ventricular septal rupture (VSR) and left ventricular aneurysm (LVA), are rare but life-threatening.Early diagnosis is critical. A ventricular septal defect (VSD) requires immediate surgical closure, while surgery for LVA is only considered in specific cases such as chest pain or thromboembolism.Diagnostic tools such as echocardiography and left ventriculography play a vital role in identifying and characterising these complications, enabling timely treatment decisions.

An updated Lagrangian constrained mixture model of pathological cardiac growth and remodelling

Progressive left ventricular (LV) growth and remodelling (G&R) is often induced by volume and pressure overload, characterized by structural and functional adaptation through myocyte hypertrophy and extracellular matrix remodelling, which are dynamically regulated by biomechanical factors, inflammation, neurohormonal pathways, etc. When prolonged, it can eventually lead to irreversible heart failure. In this study, we have developed a new framework for modelling pathological cardiac G&R based on constrained mixture theory using an updated reference configuration, which is triggered by altered biomechanical factors to restore biomechanical homeostasis. Eccentric and concentric growth, and their combination have been explored in a patient-specific human LV model under volume and pressure overload. Eccentric growth is triggered by overstretching of myofibres due to volume overload, i.e. mitral regurgitation, whilst concentric growth is driven by excessive contractile stress due to pressure overload, i.e. aortic stenosis. Different biological constituent's adaptations under pathological conditions are integrated together, which are the ground matrix, myofibres and collagen network. We have shown that this constrained mixture-motivated G&R model can capture different phenotypes of maladaptive LV G&R, such as chamber dilation and wall thinning under volume overload, wall thickening under pressure overload, and more complex patterns under both pressure and volume overload. We have further demonstrated how collagen G&R would affect LV structural and functional adaption by providing mechanistic insight on anti-fibrotic interventions. This updated Lagrangian constrained mixture based myocardial G&R model has the potential to understand the turnover processes of myocytes and collagen due to altered local mechanical stimuli in heart diseases, and in providing mechanistic links between biomechanical factors and biological adaption at both the organ and cellular levels. Once calibrated with patient data, it can be used for assessing heart failure risk and designing optimal treatment therapies. STATEMENT OF SIGNIFICANCE: Computational modelling of cardiac G&R has shown high promise to provide insight into heart disease management when mechanistic understandings are quantified between biomechanical factors and underlying cellular adaptation processes. The kinematic growth theory has been dominantly used to phenomenologically describe the biological G&R process but neglecting underlying cellular mechanisms. We have developed a constrained mixture based G&R model with updated reference by taking into account different mechanobiological processes in the ground matrix, myocytes and collagen fibres. This G&R model can serve as a basis for developing more advanced myocardial G&R models further informed by patient data to assess heart failure risk, predict disease progression, select the optimal treatment by hypothesis testing, and eventually towards a truly precision cardiology using in-silico models.

Left ventricular pseudoaneurysmectomy in patient without hemodynamic instability: A case report

We present a case of a 66-year-old male with a history of two previous diagnoses of myocardial infarction, followed by drug-eluting stent implantation. During the check-up, he complained of dyspnea, fatigue, and dizziness. Echocardiography revealed a massive left ventricular pseudoaneurysm (LVP). According to the patient's clinical manifestations and radiologic data, urgent surgical intervention was performed. Postoperatively, several complications appeared, which were managed successfully. The patient was discharged in stable condition. This is an interesting case of massive LVP without hemodynamic instability.

Prognostic value of carbohydrate antigen 125 in patients undergoing surgical left ventricular reconstruction

BACKGROUND

Carbohydrate antigen 125 (CA125) is a biomarker often used in diagnosis of ovarian tumors. Studies also show that elevated CA125 implicates worse outcomes among patients with heart failure, while latter of which plays an important role in the pathophysiology of left ventricular aneurysm (LVA). However, the prognostic value of CA125 in LVA patients undergoing surgical left ventricular reconstruction (SLVR) remains unclear.

METHODS

In this single-centered cohort study, a total of 309 patients with LVA undergoing SLVR were retrospectively recruited. Univariable regression analysis was performed to identify the potential confounders for each outcome, followed by multivariable adjustment to confirm the association between CA125 and outcomes. The primary outcome was the overall mortality, and the secondary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE) and perioperative outcomes. A receiver operating characteristic (ROC) curve was use to find the optimal cut-off value of CA125.

RESULTS

The median follow-up time was 55 months. The cohort was predominantly male (86.4%), with an average age of 58.6 years. Log (CA125) was associated with overall mortality (hazard ratio [HR]: 2.15, 95% confidence interval [CI]: 1.06-4.36, P = 0.033), prolonged hospital-stay time (HR:1.07, 95%CI: 1.03-1.12, P = 0.001) and increased risk of postoperative ventricular support (HR: 2.81, 95%CI: 1.10-7.18, P = 0.031) after multivariate adjustment. The optimal cut-off value for the CA125 for all-cause mortality was 13.825 U/ml with the area under curve of 0.675.

CONCLUSION

Elevated-CA125 implicates poorer short- and long-term prognosis in LVA patients undergoing SLVR.

Whole-Heart Tissue Engineering and Cardiac Patches: Challenges and Promises

Despite all the advances in preventing, diagnosing, and treating cardiovascular disorders, they still account for a significant part of mortality and morbidity worldwide. The advent of tissue engineering and regenerative medicine has provided novel therapeutic approaches for the treatment of various diseases. Tissue engineering relies on three pillars: scaffolds, stem cells, and growth factors. Gene and cell therapy methods have been introduced as primary approaches to cardiac tissue engineering. Although the application of gene and cell therapy has resulted in improved regeneration of damaged cardiac tissue, further studies are needed to resolve their limitations, enhance their effectiveness, and translate them into the clinical setting. Scaffolds from synthetic, natural, or decellularized sources have provided desirable characteristics for the repair of cardiac tissue. Decellularized scaffolds are widely studied in heart regeneration, either as cell-free constructs or cell-seeded platforms. The application of human- or animal-derived decellularized heart patches has promoted the regeneration of heart tissue through in vivo and in vitro studies. Due to the complexity of cardiac tissue engineering, there is still a long way to go before cardiac patches or decellularized whole-heart scaffolds can be routinely used in clinical practice. This paper aims to review the decellularized whole-heart scaffolds and cardiac patches utilized in the regeneration of damaged cardiac tissue. Moreover, various decellularization methods related to these scaffolds will be discussed.

Post-traumatic Left Ventricular Apical Aneurysm With Endoluminal Thrombus

Here, we report a case of a 54-year-old man who presented with complications of a left ventricle apical aneurysm, which was the result of a myocardial infarction (MI). Interestingly, he sustained the MI following a cardiac contusion whilst playing rugby 32 years ago. He had another MI 10 years later, despite the presence of normal coronary angiography following the initial event, and presented with two episodes of sustained ventricular tachycardia over six months. The patient proceeded to surgical resection of the aneurysm and went on to make a good recovery.

Dapagliflozin attenuates residual cardiac remodeling after surgical ventricular reconstruction in mice with an enlarged heart after myocardial infarction

BACKGROUND

Severe heart failure refractory to conventional therapy requires alternative treatment modalities. Surgical ventricular reconstruction (SVR) has been used to reverse cardiac remodeling in post-myocardial infarction (MI) patients with large left ventricular (LV) aneurysm, however, residual LV remodeling and dysfunction remain postoperatively. It is unclear whether SVR recovers response to drug treatment and whether the sodium-glucose co-transporter 2 inhibitor dapagliflozin (DAPA) reverses residual LV remodeling after SVR.

METHODS

Adult male C57 mice were subjected to MI or sham surgery. Four-week later, MI mice with LV aneurysm underwent modified SVR or second open-chest sham operation and were randomized to DAPA or vehicle for four-week. Cardiac remodeling, LV function, and the underlying mechanisms were evaluated by echocardiography, invasive LV hemodynamic measurements, mRNA sequencing, and bioinformatics analysis.

RESULTS

SVR significantly decreased LV volume; increased myocardial strain, LV pressure change rates and end-systolic elastance; and decreased heart-to-body weight ratio and myocardial fibrosis. However, significant residual cardiac remodeling remained. DAPA significantly attenuated residual cardiac remodeling and improved LV function in SVR mice but did not have curative effects in non-SVR mice. Of the 1532 genes differentially expressed in SVR and MI mice, 1037 were associated with cardiac metabolism; Src, Crebbp, Fn1, Grb2, and Mapk14 were the top 5 hub genes. Unlike sham surgery, MI upregulated those 5 genes, and treatment with SVR + DAPA normalized their expression.

CONCLUSIONS

SVR restores therapeutic response in the post-MI heart with large LV aneurysm, and DAPA attenuates residual cardiac remodeling after SVR by normalizing some cardiac metabolism-related hub genes.

Myocardial Infarction With Ventricular Wall Aneurysm: A Case Report

A ventricular aneurysm can be pseudo or true; it is a rare complication of myocardial infarction induced by an intra-myocardial dissecting hematoma due to fragile myocardium. Ventricular wall rupture takes place two to four days after myocardial infarction when coagulative necrosis and inflammatory infiltrate and lysis of myocardial connective tissue results in weakening of infarcted myocardium. Acute cardiac wall ruptures are mostly fatal; an unwittingly located pericardial adhesion can abort a rupture resulting in a false aneurysm. The wall of a false aneurysm consists of the epicardium in contrast to a true aneurysm, which is composed of the myocardium. True aneurysms are complications seen in transmural infarcts. Thinned-out scar tissue paradoxically bulged during systole, and toughened fibrotic wall rupture doesn't usually occur. Deaths in subjects with true ventricular aneurysms occur due to mural thrombus, arrhythmias, and heart failure. We encountered a case of a true aneurysm, as reported below.

Double Gain: The Radio Frequency Catheter Ablation of Ventricular Aneurysm Related Recurrent Ventricular Tachycardia on a Tremendous Cardiac Outpouching

Dilated cardiomyopathy (DCM) is a classic type of non-ischemic cardiomyopathy. Of these, idiopathic cardiomyopathy (IDCM) is a rare type of non-genetic dilated cardiomyopathy. More specifically, the patient had suspected IDCM combined with sustained polymorphic ventricular tachycardia (PMVT) of left ventricular basal segmental origin, cardiac systolic dysfunction and an ejection fraction (EF) of 29%. He had an abnormally large ventricular aneurysm (VA) in the posterior wall of the left ventricle with left ventricular end diastolic dimension (LVDd) of 90 mm. We performed an endocardial radiofrequency catheter ablation (RFCA) of the patient’s recurrent ventricular tachycardia (VT) on the basis of an implantable cardioverter (ICD). Although minimally invasive RFCA also carries a high risk, it is currently a two-pronged option to improve the patient’s quality of life and to prevent the recurrence of VT. Postoperatively, the patient was routinely given optimal anti-arrhythmic and heart failure (HF) treatments to improve cardiac function as well as being followed up for 9 months. The patient’s EF ascended to 36% without any recurrence of VT. In summary, RFCA of suspected IDCM combined with VA and VT of basal area origin would be an effective treatment.

Mending the broken valentine heart: a case report

Background

Mortality from myocardial infarction (MI) has been decreasing since the introduction of primary percutaneous intervention. Late complications still pose a dilemma, such as deterioration of left ventricle (LV) function, LV aneurysms, and LV thrombus formation. If not adequately managed in a timely manner, this can result in life-threatening consequences. Restoration of LV function by surgical resection of the infarcted LV wall is an option for a few complicated cases, with variable outcomes.

Case summary

A 66-year-old man presented with dyspnoea 2 years after his initial MI, which was treated with a drug-eluting stent to his left circumflex artery. His Warfarin had been stopped after 6 months of treatment of a small LV thrombus, which was noted at the time of his initial infarction. His echocardiogram on admission demonstrated severe LV systolic impairment of 23% (which had deteriorated from 40%) with a giant true aneurysm of the basal to mid-lateral wall, which resembled a Valentine heart. The presence of a large, organized thrombus filling the aneurysm complicated the case further. The patient underwent a resection of the LV aneurysm and thrombus. He remained asymptomatic and maintained a significant improvement of his LV function to 47% at his 5 months scan.

Discussion

The importance of imaging post-large MI and follow-up imaging once thrombus resolution has occurred is crucial. Patients with large LV aneurysm associated with severe refractory LV impairment and LV thrombus should be considered for LV aneurysmectomy for prognostic benefit and symptom relief.

Surgical Reconstruction of a Left Ventricular Aneurysm Using an Extracellular Matrix Patch

The left ventricular aneurysm is a pathological condition defined as an akinetic or dyskinetic area of the left ventricle (LV) wall associated with reduced ejection fraction. The most common surgical technique to reconstruct a left ventricular aneurysm is endoventricular patch plasty (Dor procedure). In this case, endoventricular reconstruction of the left ventricular aneurysm using a double-layer extracellular matrix was performed.

Prognostic value of ventricular mechanical dyssynchrony in patients with left ventricular aneurysm: A comparative study of medical and surgical treatment

BACKGROUND

The prognostic value of left ventricular (LV) mechanical dyssynchrony (MD) in patients with LV aneurysm (LVA) is unclear. This study aimed to investigate the long-term prognostic value of LVMD in LVA patients.

METHODS

92 consecutive patients who underwent 99mTc-sestamibi-gated SPECT myocardial perfusion imaging (GSPECT) were retrospectively analyzed and followed-up for a median of 63 months (range, 1-73 months). LV function and histogram bandwidth (BW) were analyzed by QGS software. LVMD was defined by ROC analysis. Cardiac death was defined as the primary endpoint, and the composite of cardiac deaths and severe or acute heart failure (MACE) as the secondary endpoint.

RESULTS

The annual cardiac mortality rate of LVA patients with LVMD and treated by surgical therapy was significantly lower than those treated by medical therapy (2.40% vs. 6.40%, P < .05) but not annual MACE rate (6.61% vs. 10.06%, P > .05). In patients without LVMD, no significant difference in survival and MACE-free survival between medical and surgical treatment. In addition, the occurrence of LVMD is related to the worsen cardiac outcome in terms of MACE and cardiac death, independent of the treatment methods. BW was an independent predictor for MACE (HR 1.010, P < .01) and LVEF (HR .928, P < .05) was an independent predictor for cardiac death in all LVA patients.

CONCLUSIONS

LVA patients with LVMD might be associated with high risk for cardiac death and surgical treatment might improve cardiac survival compared to medical therapy in these patients.

A Modified Surgical Ventricular Reconstruction in Post-infarction Mice Persistently Alleviates Heart Failure and Improves Cardiac Regeneration

Objectives: Large ventricular aneurysm secondary to myocardial infarction (MI) results in severe heart failure (HF) and limits the effectiveness of regeneration therapy, which can be improved by surgical ventricular reconstruction (SVR). However, the conventional SVR procedures do not yield optimal long-term outcome in post-MI rodents. We hypothesized that a modified SVR procedure without aggressive purse string suture would persistently alleviate HF and improve cardiac regeneration in post-MI mice.

Methods: Adult male C57 mice were subjected to MI or sham surgery. Four weeks later, mice with MI underwent SVR or 2nd open-chest operation alone. SVR was performed by plicating the aneurysm with a single diagonal linear suture from the upper left ventricle (LV) to the right side of the apex. Cardiac remodeling, heart function and myocardial regeneration were evaluated.

Results: Three weeks after SVR, the scar area, LV volume, and heart weight/body weight ratio were significantly smaller, while LV ejection fraction, the maximum rising and descending rates of LV pressure, LV contractility and global myocardial strain were significantly higher in SVR group than in SVR-control group. The inhibitory effects of SVR on LV remodeling and HF persisted for at least eight-week. SVR group exhibited improved cardiac regeneration, as reflected by more Ki67-, Aurora B- and PH3-positive cardiomyocytes and a higher vessel density around the plication area of the infarcted LV.

Conclusions: SVR with a single linear suture results in a significant and sustained reduction in LV volume and improvement in both LV systolic and diastolic function as well as cardiac regeneration.

A new classification of chronic postinfarction aneurysms of the left ventricle in patients with coronary artery disease

The article highlights the historical moments of how the concepts for the diagnosis and treatment of postinfarction aneurysms of the left ventricle were developed, and the possibilities of the main diagnostic methods. As a rule, patients with chronic postinfarction aneurysms of the left ventricle have severe damage to their coronary bed, requiring invasive correction (coronary artery stenting or coronary artery bypass grafting), which must be performed either before or during the intervention to eliminate the left ventricular aneurysm. A new classification of chronic postinfarction aneurysms of the left ventricle is proposed, which takes into account rather the type of myocardial blood supply and the severity of damage to the coronary bed, than the actual features of aneurysms. It determines the stages and tactics of treatment of patients with chronic postinfarction aneurysms of the left ventricle, focusing on the problem of coronary revascularization.

A historical appraisal of the techniques of left ventricular volume reduction in ischemic cardiomyopathy: Who did what?

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

Incidental Discovery of a Left Ventricular Aneurysm After a Syncopal Episode

A left ventricular aneurysm is a rare post myocardial infarction complication. Ventricular aneurysms form as post-ischemic cardiac remodeling creates a weaker, fibrotic area that may bulge outwards against interventricular pressures over time. Patients with ventricular aneurysms have increased mortality and are at higher risk of various cardiac complications, such as cardiac arrest, arrhythmias, thrombus formation, reduced cardiac output, or aneurysmal rupture. Prompt diagnosis and treatment are critically important in these patients. We highlight the hospital course of a patient with an extensive cardiac history presenting for syncope with the discovery of a left ventricular aneurysm. The radiographic features of the left ventricular aneurysm are described, as well as formation, risk factors, and complications.

Patient selection for LIVE therapy: From clinical indications to multimodality imaging individual case planning

BACKGROUND

Less Invasive Ventricular Enhancement (LIVE) with Revivent TC is an innovative therapy for symptomatic ischemic heart failure (HF). It is designed to reconstruct a negatively remodeled left ventricle (LV) after an anterior myocardial infarction (MI) by plication of the scar tissue. Its indications are specific, and as with any other structural heart intervention, the success of the procedure starts with appropriate patient selection. We aim to present the indications of the technique, crucial aspects in patient selection, and individual case planning approach.

METHODS AND RESULTS

After clinical evaluation, transthoracic echocardiography is the first imaging modality to be performed in a potential candidate for the therapy. However, definitive indication and detailed case planning rely on late gadolinium-enhanced cardiac magnetic resonance imaging or multiphasic contrast-enhanced cardiac computed tomography. These imaging modalities also assist with relative or absolute contra-indications for the procedure. Individual assessment is done to tailor the procedure to the specifics of the LV anatomy and location of the myocardial scar.

CONCLUSION

LIVE procedure is a unique intervention to treat symptomatic HF and ischemic cardiomyopathy after anterior MI. It is a highly customizable intervention that allows a patient-tailored approach, based on multimodality imaging assessment and planification.

Endoventricular Pericardial Patch Repair of a Giant Left Posterior Ventricular Aneurysm

BACKGROUND/AIM

Left ventricular aneurysms are complications following acute myocardial infarction. Left posterior left ventricular aneurysms occurring in a submitral position constitute a minor entity, and those leaving the mitral apparatus intact are extremely rare.

CASE REPORT

Herein, we report the case of a 58-year-old patient with a past medical history of coronary artery disease and myocardial infarction with a giant left posterior left ventricular aneurysm with moderate mitral valve incompetence.

RESULTS

The patient underwent myocardial revascularization and, through a transaneurysmal approach, successful endoventricular pericardial patch wall reconstruction with no impact on mitral valve competence.

CONCLUSION

Whenever the mitral valve is not affected, a trans aneurysmal approach with endoventricular pericardial patch in association with myocardial revascularization represents a safe and reproducible approach with good functional outcomes.

Surgical management of a giant congenital left ventricular aneurysm in a 2-month-old infant

A congenital left ventricular aneurysm is very rare. Clinical presentation varies from absence of symptoms to ventricular arrhythmias, heart failure or even sudden death. The optimal management is controversial and the surgical technique is not defined. A left ventricular aneurysm was diagnosed on prenatal echocardiography at 33 weeks gestation. After birth, initial transthoracic echocardiography confirmed the diagnosis. Two months later, the infant was taken to surgery for aneurysm repair using the Dor procedure with cardiopulmonary bypass. This technique eliminates the need for external prosthetic materials and produces a more physiologic left ventricular geometry. Transthoracic echocardiography performed at 6-month follow-up showed an ejection fraction of 66%.

Surgery for Ventricular Tachycardia

The treatment of drug-refractory chronic ventricular tachycardia (VT) has undergone a revolution over the last 50 years. We now have automatic implantable cardioverter defibrillator therapy with pace-terminating capabilities, and catheter ablation of VT has refined mapping and improved methods of lesion generation. Between 1980 and 1993, Houston Methodist Hospital became a leader in the diagnosis and surgical ablation of VT and other arrhythmias. This is a brief account of that period and some of the experiences and lessons that have led to significant advances used today.

Predictors and long-term prognosis of left ventricular aneurysm in patients with acute anterior myocardial infarction treated with primary percutaneous coronary intervention in the contemporary era

Background

Primary percutaneous coronary intervention (PCI) has been the standard reperfusion strategy for patients with acute myocardial infarction (AMI) in the contemporary era. Meanwhile, the incidence and prognosis of left ventricular aneurysm (LVA) in AMI patients remain ambiguous. The aim of the current study is to identify the predictor and long-term prognosis of LVA in patients with acute anterior myocardial infarction.

Methods

We prospectively enrolled 942 consecutive patients with acute anterior myocardial infarction who were treated by primary PCI. The baseline characteristics, procedural features, and one-year clinical outcomes were compared between the patients with and without LVA. The primary endpoint of major adverse cardiovascular and cerebrovascular events (MACCEs) was defined as a composite of cardiac death, target vessel revascularization, and ischemic stroke. Multiple logistic regression was applied to predict LVA formation and the receiver operating characteristic (ROC) curves were plotted to evaluate the accuracy of the multivariate analysis model.

Results

The general incidence of LVA was 15.92%. At one-year clinical follow-up, patients in the LVA group had significantly higher incidence of MACCEs (15.33% vs. 6.44%, P<0.01), mainly driven by an increased incidence of cardiac death (8.00% vs. 2.78%, P<0.01), target vessel revascularization (5.33% vs. 2.27%, P=0.03), and ischemic stroke (4.00% vs. 1.39%, P=0.03). Multivariate analysis found that longer symptom-to-balloon time (S2B) [odds ratio (OR): 1.16, 95% confidence interval (CI): 1.11–1.21, P<0.01], higher initial and residual SYNTAX score (iSS, OR: 1.19, 95% CI: 1.14–1.24, P<0.01; rSS, OR: 1.33, 95% CI: 1.22–1.45, P<0.01), lower left ventricular ejection fraction (LVEF) (OR: 1.15, 95% CI: 1.11–1.18, P<0.01), and persistent ST segment elevation (OR: 1.89, 95% CI: 1.06–3.38, P=0.03) were independent predictors of LVA formation.

Conclusions

LVA is still common in patients with acute anterior myocardial infarction in the contemporary PCI era, and the prognosis of these patients was significantly worse during the one-year clinical follow-up. Strategies of prompt reperfusion and complete revascularization may be helpful in preventing LVA formation and improving clinical outcomes.

Anesthetic Considerations for a Novel Method of Surgical Ventricular Remodeling Using the BioVentrix Revivent TC System

Surgical ventricular remodeling (SVR) is an invasive method of treating patients with heart failure who also have ischemic cardiomyopathy and reduced ejection fraction (EF). Introduced in the mid-1980s, this technique was met with varying success and relatively high morbidity and mortality despite its theoretical benefits. The development of the BioVentrix Revivent TC System (BioVentrix, Inc., San Ramon, CA) as a less-invasive method of surgical ventricular remodeling has created a novel, multidisciplinary approach to heart failure management, which necessitates multiple subspecialties. Currently in the trial phase in the United States and widely used in Europe, the positive results to date appear promising for the rapid adoption of this procedure. For the cardiac anesthesiologist, a thorough understanding of the patient population, procedural goals, and intraoperative management is essential. This overview discusses the advancement in surgical ventricular remodeling, the pertinent surgical steps of the BioVentrix Revivent TC System placement, and specific anesthetic considerations for this novel procedure.

Percutaneous closure of left ventricular pseudoaneurysm in a patient with concomitant true left ventricular aneurysm

BACKGROUND

Left ventricular aneurysms (LVA) are serious complications of myocardial infarction, being divided into true and false type. The false one-pseudoaneurysm (PA), is a life-threatening condition that requires urgent treatment due to the high risk of rupture.

CASE PRESENTATION

An 84-year-old female presented with progressive heart failure symptoms. Investigation showed a small true LVA and a large PA. Open surgical repair was ruled out as Euroscore and Society of Thoracic Surgeons (STS) score were 42.80% and 39.97%, respectively. After discussion at our Heart Team meeting, percutaneous approach was found to be the best option. Guided by transesophageal echocardiography, we used an interventricular septal defect occluder to close the gap between the LV and the PA. Control ventriculography showed full closure of the gap, with no residual flow to the PA cavity. The patient was discharged from the hospital on the fifth postoperative day and has remained asymptomatic since then.

CONCLUSION

Percutaneous approach proved to be a safe and effective modality to treat LV PA. The device implanted achieved the goal of blocking blood flow through the communication between LV and the PA.

Impact of revascularization in patients with post-infarction left ventricular aneurysm and ventricular tachyarrhythmia

Background

Ventricular arrhythmia is a leading cause of cardiac death among patients with post‐infarction left ventricular aneurysm (PI‐LVA). The effect of coronary revascularization in PI‐LVA patients with ventricular tachyarrhythmia remains unknown. This study aims to investigate the impact of revascularization therapy on clinical outcomes in these patients.

Methods

A total of 238 PI‐LVA patients were enrolled, and 59 patients were presented with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Patients were classified into 4 groups by treatment strategies (medical or revascularization) and the presence of VT/VF: group 1 (n = 57): VT/VF− and revascularization−; group 2 (n = 122): VT/VF− and revascularization+; group 3 (n = 34): VT/VF+ and revascularization+; and group 4 (n = 25): VT/VF+ and revascularization‐. The clinical outcomes were compared, and the primary endpoint was cardiac death or heart transplantation.

Results

Patients were followed up for 45 ± 16 months, and 41 patients (17.2%) reached the primary endpoint. Kaplan–Meier analysis showed that in VT/VF− patients, revascularization associated with higher cardiac survival compared with medical therapy (log‐rank p = .002), but in VT/VF+ patients, revascularization did not predict better cardiac outcome (log‐rank p = .901). Cox regression analysis revealed PET‐EF (HR 4.41, 95% CI: 1.72–11.36, p = .002) and moderate/severe mitral regurgitation (HR 2.32, 95% CI: 1.02–5.30, p = .046) as independent predictors of adverse cardiac outcome in patients with VT/VF.

Conclusion

PI‐LVA patients with VT/VF are at high risk of adverse cardiac outcome, and coronary revascularization does not mitigate this risk, although revascularization was associated with higher cardiac survival in PI‐LVA patients without VT/VF.

Giant Left Ventricular (Pseudo?) Aneurysm Complicating Anterior Myocardial Infarction

The differential diagnosis of true aneurysms and pseudoaneurysms is challenging, and multimodality cardiac imaging is often necessary. We report a case in which the limitations of these techniques are exposed, showing that post-operative evaluation of tissue layers remains the gold standard in establishing this diagnosis. (Level of Difficulty: Beginner.)

Left Ventricular Aneurysm Repair: Off-pump Linear Plication versus On-pump Patch Plasty

Objective

The study aimed to compare the clinical outcomes of simplified linear plication and classic patch plasty in patients with left ventricular aneurysm (LVA).

Methods

We retrospectively reviewed 282 patients undergoing LVA repair between 2006 and 2016. After propensity score matching, 45 pairs of patients receiving LVA surgery were divided into either a patch group (on-pump endoventricular patch plasty) or a plication group (off-pump linear plication). Then, their early surgical outcomes and long-term survival were compared in two matched groups.

Results

The heart function improvement at discharge was similar in the two matched groups, while patients in the patch group more commonly suffered from low cardiac output syndrome (P=0.042) with higher proportion of intra-aortic balloon pumping assistance (P=0.034) than patients in the plication group. Compared with patients in the patch group, the patients in the plication group had shorter recovery times, regarding to mechanical ventilation, intensive care unit stay, and hospital stay (P<0.001, P<0.001, and P=0.001, respectively). No significant difference was found in the long-term survival (P=0.62).

Conclusions

Off-pump linear plication presented acceptable results in terms of early outcomes and long-term survival. For high-risk patients, the simplified LVA repair technique may be an option.

Myocardial Metastasis of Cutaneous Squamous Cell Carcinoma in a Burn Patient

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The patient presented with fungating skin lesions, remitting fevers, and leukocytosis.

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Myocardial perfusion echocardiography aided in the diagnosis of neoplasm in the RVOT.

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Fluoroscopy-guided biopsy of the mass confirmed metastatic invasion of SCC.

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Evidence for optimal management of cardiac metastasis of SCC is scarce.

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This is the first reported case of Marjolin's ulcer with metastasis to the heart.

Resistant Ventricular Tachycardia due to Idiopathic Left Ventricular Aneurysm: Successful Treatment with Surgery

Left ventricular aneurysms (LVAs) are characterized by a wide connection to the left ventricle and paradoxical systolic motions. Although patients with LVAs are usually asymptomatic, some may present with arrhythmias, heart failure, and even cardiac arrest. In this case report, we describe a 62-year-old male patient who presented to our emergency service with complaints of palpitation and shortness of breath of 2 hours' duration. His blood pressure was 84/56 mm Hg, and he was in a confused state. An electrocardiogram revealed ventricular tachycardia (VT) with right bundle branch block and a ventricular rate of 188 bpm. The patient's hemodynamic instability necessitated a direct current cardioversion, which restored the sinus rhythm. During the in-hospital course, he had numerous recurrent VT episodes despite treatment with intravenous amiodarone and magnesium sulfate as well as radiofrequency ablation. Upon consensus with a cardiovascular surgeon's team, urgent surgery was performed due to the resistant VT episodes. The patient's clinical course was uneventful, and he was discharged on the 11th postoperative day. We have been following up the patient for almost 1 year, during which he has not experienced palpitations or associated symptoms. Our case indicates that surgery may be a preferable treatment option for patients with heart failure and resistant VT related to LVAs.