Management Of Left Ventricular Aneurysms Research Articles

Rare silent ischemic ventricular septal aneurysm and rupture: A multimodality diagnostic approach.

A multimodality approach in addition to high level of clinical suspicion and thorough physical examination is important in the diagnosis and management of left ventricular aneurysm and rupture after a silent inferior infarction.

Post infarction left ventricular aneurysm—our experience

Left ventricular aneurysms (LVAs) stand as one of the serious complications of myocardial infarction and are associated with increased mortality. Considerable differences exist regarding the optimal surgical management of LVAs. In this study, we report our single center/single surgeon experience with post infarction LVAs. This is a retrospective analysis of 25 patients, who underwent endoventricular circular patch plasty (Dor procedure) for LVAs of ischemic origin from 2009 to 2013. The demographic data was collected in addition to patients mode of presentation, New York Heart Association (NYHA) class, past medical history particularly ischemic heart disease, preoperative electrocardiography, chest X-ray, echocardiography, and coronary angiography. The postoperative functional class and the echocardiography data were also collected and analysed. All patients underwent follow-up cardiac computerized tomogram (CT) scan to calculate the sphericity index (SI). The mean age of presentation was 60.76 ± 9.57 years. Seventeen were males and eight were females. The associated comorbidities were, diabetes and hypertension. The most common presentations were, the angina and the left ventricular failure. Among the study group, two (8%) patients presented within 72 h of myocardial infarction (MI) owing to the hemodynamic instability due to ventricular septal rupture (VSR) and severe mitral regurgitation (MR), and required moderate doses of inotropes and intra-aortic balloon pump. The time of presentation in the remaining 23 (92%) patients ranged from 14 to 38 days following the MI (mean −21.36 ± 0.38 days). The preoperative mean NYHA functional class was 2.44 ± 0.71. Posterior aneurysms were predominated in our study. The mean left ventricular internal diameter in diastole (LVIDd), the left ventricular internal diameter in systole (LVIDs) and the ejection fraction (EF) were; 6.52 ± 0.40 cm, 5.24 ± 0.37 cm, and 37.44 ± 3.92% respectively. The mean end-diastolic volume (EDV) was 167 ± 28.38 ml and the mean end-systolic volume (ESV) was 87.84 ± 12.90 ml. The mean pulmonary artery systolic pressure (PASP) was 51.48 ± 5.72 mmHg. The mean tricuspid annular plane systolic excursion (TAPSE) was 11.52 ± 0.71 mm. Six cases showed mural thrombus, four had MR, and one had an associated ventricular septal defect (VSD). The coronary angiogram showed multivessel coronary artery disease in majority of patients. The hospital mortality was 8% (two cases). The mean follow-up period was 2.4 ± 0.91 years. The postoperative mean NYHA class was 1.76 ± 0.43. There was a significant improvement in the left ventricular function. There was a significant improvement in MR following concomitant Dor procedure and mitral valve interventions. Patients with mitral interventions had trivial to mild MR and were asymptomatic. The mean SI was 0.5 ± 0.11. Dor procedure is reproducible and simple to perform, restores the natural left ventricular geometry and is associated with significant improvement in the left ventricular performance and hemodynamics, which translates into improved functional class of the patient.

Management of Left Ventricular Aneurysm: A Study from Iraq

Background: The most appropriate surgical approach for post-myocardial infarction left ventricular aneurysm (LVA) is controversial. This study aims to display the results of surgical treatment of LVA in a major Iraqi cardiac surgical center. Methods: The surgical management of LVAs over the period 2001 to 2011 was retrospectively reviewed. The presenting signs and symptoms, results of investigations, operative findings, and outcomes of patients were determined. Results: Twenty-seven true LVAs associated with 4 ventricular septal defects (VSDs) were treated surgically. During the same period, 1136 coronary artery bypass graft (CABG) operations were done, thus LVA represented 2.4%. Males constituted the majority (74.1%). The mean age was 54.6 years old. The typical ECG changes were seen in 42.1%. Apical and antero-apical locations predominated. The majority of patients (84.2%) had subnormal values of ejection fraction (EF). Most patients had multi-vessel coronary artery disease (CAD). The most frequent was the left anterior descending artery (LAD). All patients had CABG except 3. Linear repair and Dor technique were used equally. The commonest postoperative complication was bleeding (38.4%). The overall hospital mortality was 18.5%. Conclusion: Concomitant CABG improves early postoperative course and must be added when significant lesions in coronary arteries particularly the LAD are present.

Surgical Management of Left Ventricular Aneurysms by Endoventricular Pericardial Patch Plasty

Background: Early and late surgical outcomes of endocardial resection and aneursymectomy repaired with an autologous pericardial patch were studied. Methods: We studied 125 patients who underwent endoaneurysmorrhaphy with pericardial patch during the period from June 1993 until June 2000. Preoperative, early and late postoperative results, annual postoperative echocardiography of all patients and hemodynamic controls of 35 patients within a mean follow-up of 64±8 months were analyzed. Results: Mean NYHA improved to postoperative 2.1±0.5 from preoperative 2.8±0.4. Mean number of bypass grafts was 2.6±1.1. Left ventricular ejection fraction rate improved to 36.2±8% in one month. 39.3±9% in 6 months, 42.3±8% in one year versus preoperative 29.2±9% (P≤0.05). Perioperative mortality was 6.4% (eight patients) and 11 deaths were observed in the late follow-up (9.4%). Conclusion: Endoaneurysmorrhaphy with pericardial patch may be an alternative option in the management of left ventricular aneurysms within acceptable surgical results.

Surgical management of left ventricular aneurysms by endoventricular pericardial patch plasty

Background: Early and late surgical outcomes of endocardial resection and aneursymectomy repaired with an autologous pericardial patch were studied.Methods: We studied 125 patients who underwent endoaneurysmorrhaphy with pericardial patch during the period from June 1993 until June 2000. Preoperative, early and late postoperative results, annual postoperative echocardiography of all patients and hemodynamic controls of 35 patients within a mean follow-up of 64±8 months were analyzed.Results: Mean NYHA improved to postoperative 2.1±0.5 from preoperative 2.8±0.4. Mean number of bypass grafts was 2.6±1.1. Left ventricular ejection fraction rate improved to 36.2±8% in one month, 39.3±9% in 6 months, 42.3±8% in one year versus preoperative 29.2±9% (P≤0.05).Perioperative mortality was 6.4% (eight patients) and 11 deaths were observed in the late follow-up (9.4%).Conclusion: Endoaneurysmorrhaphy with pericardial patch may be an alternative option in the management of left ventricular aneurysms within acceptable surgical results.

Surgical Management of Left Ventricular Aneurysms by the Jatene Technique

Few significant improvements in left ventricular aneurysm (LVA) surgery occurred from the time of Cooley’s report of the first open resection using cardiopulmonary bypass in 1958l until Jatene2 and Dor3 reported entirely new reparative approaches in the mid-1980s. Most LVAs occur in the anteroseptal region and, as the name would imply, involve not only the anterior portion of the free-wall of the left ventricle but also the distal ventricular septum. Jatene realized that simple aneurysm resection and linear closure did nothing to correct the septa1 component of anteroseptal aneurysms and the first objective of his new approach was to overcome that deficiency. He did so by introducing the concept of imburcating the involved portion of the septum in order to stabilize it and to give the left ventricular free-wall a firm base against which it could contract. Jatene also recognized that most anteroseptal aneurysms, certainly the larger ones, had dilated bases and that the dilitation of the aneurysm base pulled the non-aneurysmal left ventricular free-wall away from the septum (Fig 1). It seemed intuitive to him that this morphologic change in the geometry of the left ventricle would have the effect of decreasing global ventricular function independent of the more direct and apparent adverse effects of the aneurysm. Furthermore, if the base of the resected aneurysm were allowed to persist in its dilated state, the induced dysfunction of the nonaneurysmal left ventricular free-wall would continue to exist postoperatively. Jatene’s solution was to aUeviate that problem by placing an encircling purse-string suture around the base of the aneurysm and tightening it down until the ventricle resumed the shape it would have had if the myocardial infarction had occurred without the complication of an aneurysm. Jatene felt that by reconstructing the normal geometry of the left ventricle as much as possible while removing the aneurysm, the results of surgical therapy should improve. The Jatene technique and the similar technique described by Dor now represent the state-of-the-art in the surgical treatment

Management of Left Ventricular Aneurysm by Intracavitary Repair

Left ventricular aneurysms (LVAs) occur in up to 40% of patients after myocardial Most LVAs are caused by occlusion of the coronary arteries, most frequently the left anterior descending coronary artery, and are located in the anteroapical region of the left ventricle. They appear as circumscribed, noncontractile areas of tissue that can be identified by systolic thinning of the infarcted area of myocardium. Occasionally, LVAs result from trauma, nonspecific myocarditis, bacterial endocarditis, or congenital malformations of the heart. Whether to treat a patient with an LVA medically or surgically depends on the status of left ventricular function and on the severity of symptoms. Patients with LVAs usually have (in order of frequency) congestive heart failure (with or without angina), thromboembolism, and ventricular tachyarrhythmias. In patients with severe symptoms and medically intractable heart failure or angina, surgery is the only option. In most patients, symptoms and prognosis can be improved by repairing the aneurysm and, when necessary, by performing concomitant coronary artery bypass or valve repair. The goal of treatment is to restore normal filling volume and normal geometric chamber configuration. Until cardiopulmonary bypass became a reality, few attempts were made to correct left ventricular aneurysms. Soon after the introduction of cardiopulmonary bypass, however, we reported the first successful repair of a ventricular ane~rysm.~ In that procedure, we dissected the adherent parietal pericardium from the aneurysmal surface and then completely excised the aneurysm, trimming the edges back to the functional myocardium. Since then, we have used a variety of other techniques to repair ventricular aneurysms, including plication, septoplasty with plication, patches, septa1 patches, and overlapping and felt buttre~ses.~ Although these methods were satisfactory, each produced either distortion, papillary dysfunction, or compromised ventricular volume. In 1988, I tried a new method of repair in a few patients whose ventricular aneurysms were so large that repair by excision would have left too little normal myocardium to restore ventricular function. This technique of intracavitary repair, which I called ventricular endoaneurysmorrhaphy, differed from earlier techniques I had used4q5 and from similar techniques used by other^.^.^ Our results (detailed later) were excellent, and as our experience broadened, we began to use the endoaneurysmorrhaphy technique on even the highest-risk patients with good results. Furthermore, we found that endoaneurysmorrhaphy could be easily adapted to any situation where active myocardium was present. We now prefer this technique over any other. This report will detail the different indications and techniques of intracavitary repair that we use in the treatment of left ventricular aneurysms.

Surgical Management of Left Ventricular Aneurysms by the Endoventricular Circular Patch Plasty Technique

Surgical Management of Left Ventricular Aneurysms by the Endoventricular Circular Patch Plasty Technique

Surgical management of left ventricular aneurysm and diffuse coronary artery disease: immediate and long term results in patients receiving three or more grafts.

Because little information is available concerning the outcome of surgery for left ventricular aneurysm when multiple concurrent coronary grafts are required, we have reviewed 35 consecutive patients undergoing aneurysm surgery and multiple (greater than or equal to 3) grafts between December 1973 and April 1984. There were 6 operative deaths (17%). All occurred amongst those (16) undergoing LV plication procedures with no deaths amongst those (19) undergoing aneurysm resection (p less than 0.01). Operative mortality was not influenced by preoperative functional status, left ventricular end diastolic pressure, completeness of revascularisation, endarterectomy (13 patients) or whether cold crystalloid cardioplegia or intermittent aortic cross clamp with ventricular fibrillation was used. Overall 5-year actuarial survival was 70% with survival beyond surgery being 84% to 5 years and independent of the type of aneurysm procedure. Of the survivors, 16 were improved by 1-3 functional classes, 3 were unchanged and one was worse. Surgery in this group of patients offers the prospect of good symptomatic improvement and survival figures which at least equal the results of less complex ventricular aneurysm surgery and exceed those reported for medical management.

Prognostic Considerations in the Management of Left Ventricular Aneurysms

This report summarizes a four-year experience with 60 patients who had left ventricular aneurysm (LVA) resection and bypass of all significantly diseased coronary arteries, with an operative and late mortality of 3.3 and 8.3%, respectively. Their cardiac catheterizations were reviewed, and the only values that seemed to reflect prognosis were preoperative cardiac index and the presence or absence of septal motion. The lower the cardiac index, the less likely the patient was to do well postoperatively. There were no survivors who had lacked septal motion by left anterior oblique ventriculogram. Patients without septal motion are therefore no longer considered surgical candidates. If septal motion is present, resection of LVA carries no more risk than myocardial revascularization without LVA.

Current surgical management of left ventricular aneurysm.

One hundred thirty-two patients with ventricular aneurysm had cardiac catheterization, coronary anglography, and ventriculography. More than 50 percent of the patients, in addition to aneurysmectomy, had other procedures consisting of revascularization, mitral valve replacement, and closure of ventricular septal performation. The overall mortality was 10 percent. Aneurysmectomy alone had a higher mortality (9 percent) when compared with combined resection of the aneurysm and coronary bypass (5.4 percent). During a six-month to 4-1/2-year follow-up (mean, 21 months), seven patients died, representing a late mortality of 6 percent. This study confirms the importance of complete cardiac evaluation in patients with ventricular aneurysm and shows that, in spite of extensive combined operative procedures required in more than 50 percent of the patients, the results are favorable.