Endoventricular patch plasties with septal exclusion for repair of ischemic left ventricle: technique, results and indications from a series of 781 cases.

Abstract

Most cases of left ventricular aneurysms undergo operation through resection of the exteriorized dyskinetic area with longitudinal suturing of the opening and this technique has been considered by cardiologists (Froehlich et al) to bring no improvement to the morphology and performance of the left ventricle. Some technical modifications have been adopted, such as the septal plicature (Cooley) or circular suturing of the opening (Jatene). Since 1984 our team has used an endoventricular patch, sutured over the contractile area and excluding the akinetic non-resectable scars, bringing a significant and calculable improvement to the left ventricular function. This technique of left ventricular reconstruction (LVR), called endoventricular circular patch plasty (EVCPP) has been already used on more than 750 patients (May 97). Clinical and echographic data for each case are completed by right catheterisation with measurement of the cardiac output, pulmonary arterial pressures (PAP) and programmed ventricular stimulation (PVS), in order to detect eventual ventricular tachycardia (IVT). During left heart catheterisation, the morphology of the left ventricle (LV) is studied on right and left anterior oblique incidences and the LV ejection fraction (EF) is checked globally (GEF) and especially in its contractile portion (CEF). After surgery, a hemodynamic study associated with a PVS, is carried out during the first post-operative month, and again after one year. Results were clinically satisfactory in more than 90% of cases (8.9% of NYHA III-IV), and in more than 90% of cases with ventricular arrhythmia with the hemodynamic persistent EF at one year, superior to the pre-operative CEF. Thus we have to propose the following indications: Elective: This ventricular reconstruction can be recommended for ventricular aneurysms or akinesias with angina, arrhythmias or attacks of cardiac insufficiency, when GEF > 30% and CEF > 40%. The operative mortality rate varies from 1,5 to 3%, which is better than allowing natural evolution. Mandatory: In emergency, when safe immediate circulatory assistance or a cardiac transplant is unavailable, LVR can give hope for survival to more than 80% of patients, whereas natural evolution is without hope. Finally the operative indication is uncertain in two contrasting circumstances: In asymptomatic patients when hemodynamic and angiographic examinations after myocardial infarction show left ventricular dyskinesia. If GEF is below 40% and CEF below 50%, it seems wise to propose LVR in order to prevent unfavourable evolution. In end-stage ischemic cardiomyopathies, if the EF is below 20%, CEF is below 30%, cardiac output is below 1.5 l, and the mean pulmonary pressure is above 25, then a cardiac transplant should be considered. EVCPP with septal exclusion is a safe technique and easily reproduced when associated with coronary revascularization as far as practicable, then EVCPP improves the ventricular function. When associated with sub-total endocardectomy, then EVCPP allows excellent control of VA.