Postinfarction Left Ventricular Aneurysm Research Articles

Traumatic coronary artery dissection

A 14-year-old boy sustained blunt chest trauma resulting in dissection of the left main coronary artery, postinfarction left ventricular aneurysm, mitral regurgitation, and tricuspid regurgitation. He underwent pericardial patch angioplasty of the left main coronary artery, left ventricular aneurysmectomy, mitral valvuloplasty, and tricuspid annuloplasty. The patient continues to do well 4 years after operation.

Role of Intraaortic Balloon Pump in Left Ventricular Endoaneurysmorrhaphy

Intraaortic balloon counterpulsation has become a prerequisite for surgical repair of a left ventricular aneurysm. From October 1991 to October 1996, 60 consecutive patients underwent left ventricular endoaneurysmorrhaphy. Most had associated procedures, mainly coronary artery bypass grafting. Twenty-two patients (36.7%) were in New York Heart Association functional class III or IV preoperatively. These included 16 (26.7%) who had low cardiac output requiring an intraaortic balloon pump in the perioperative period. Pharmacological inotropic support alone was inadequate in 13 of these patients, one required a balloon pump for 5 days preoperatively due to severe low cardiac output, and 2 needed mechanical support postoperatively for ventricular arrhythmia and low cardiac output. The other 44 patients (73.3%) recovered without mechanical support. This study highlights the important role of intraaortic balloon counterpulsation in the surgical treatment of postinfarction left ventricular aneurysm.

Effects of reconstructive surgery for left ventricular anterior aneurysm on ventriculoarterial coupling

ObjectiveTo investigate left ventricular elastance (Emax) and effective arterial elastance (Ea) in postinfarction left ventricular aneurysm and evaluate their role in left ventricular function improvement after endoventricular circular patch plasty...

Postinfarction left-ventricular aneurysm: regional stress, function, and remodeling after aneurysmectomy.

Left-ventricular (LV) aneurysm formation after myocardial infarction (MI) leads to LV remodeling with global and regional cardiac dysfunction. LV aneurysmectomy (LVA) can often improve LV function, but changes of regional wall stress and systolic function in the noninfarcted segment before and after the operation remain poorly understood. The purpose of this study was to assess the effects of LVA on regional stress and systolic function in the noninfarcted region and to examine this procedure's impact on the LV remodeling in patients with LV aneurysm after myocardial infarction (MI). Using quantitative left ventriculography and pressure measurements, 11 patients with an anterior LV aneurysm were studied before and 8 months after standard linear repair (LVA group), and 10 patients with an anterior transmural infarction who received coronary artery bypass grafting were also studied (CABG group) in an attempt to separate the effects of aneurysmectomy from the effects of bypass surgery. Regional end-systolic (ESS) and end-diastolic (EDS) stresses of the contractile segment (CS) were computed by Janz's method. The total ejection fraction (EF) increased (p < 0.01) in the LVA group, whereas it did not change in the CABG group at 8 months after surgery. Both the end-diastolic and end-systolic volume indices of CS decreased (p < 0.01 and p < 0.01, respectively) in the LVA group, whereas both remained unchanged in the CABG group. The mean velocity of circumferential fiber shortening (mean Vcf) of CS increased substantially (p < 0.01) in the LVA group and, less significantly (p < 0.05), in the CABG group. Regional ESS and EDS decreased (p < 0.01 and p < 0.05, respectively) in the LVA group, whereas both remained unchanged in the CABG group. The increase in mean Vcf correlated strongly with the magnitude of decrease in ESS (r = -0.63, p < 0.01) in the LVA group but not in the CABG group. LVA can reduce regional afterload and improve ejection performance of the noninfarcted myocardium in many patients with a large anterior LV aneurysm and, moreover, may favorably affect the LV remodeling process after MI.

Repair of Left Ventricular Aneurysm: Long-Term Results of Linear Repair Versus Endoaneurysmorrhaphy

Background. Recently, endoaneurysmorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques. Methods. Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair. Results. The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 ± 0.08 versus 0.30 ± 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 ± 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 ± 0.64 versus 0.18 ± 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair ( p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 ± 0.11 versus 0.27 ± 0.11; p = 0.90), left ventricular volume (171.6 ± 59.1 versus 169.9 ± 54.4 mL; p = 0.94), and sphericity index (0.61 ± 0.09 versus 0.61 ± 0.12; p = 1.0). Conclusions. Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

The Jatene procedure for correction of post-infarction left ventricular aneurysms — results of 62 operations

The Jatene procedure for correction of post-infarction left ventricular aneurysms — results of 62 operations

Outcome of left ventricular aneurysmectomy with patch repair in patients with severely depressed pump function

To determine the efficacy of left ventricular (LV) aneurysm resection and endoventricular patch repair with septal exclusion in patients with severely depressed pump function, we retrospectively selected 62 patients (mean age 59 ± 7 years) with preoperative LV ejection fraction ≤20%, from a series or 322 patients with postinfarction LV aneurysm who underwent this type of surgery at our center during a 5-year period. Mean ejection fraction was 17 ± 3%; all patients were in New York Heart Association (NYHA) class III/IV, and all had hemodynamic and electrophysiologic studies before and after surgery. We analyzed both operative and long-term survival, and hemodynamic, electrophysiologic, and angiographic variables, as well as the symptomatic state after surgery. Follow-up was available in all patients (mean 23 ± 14 months). Subtotal endocardiectomy and cryotherapy were associated in patients presenting with spontaneous or inducible ventricular arrhythmias (VA). Hospital mortality rate was 19.3%. Ejection fraction improved from 17 ± 3% to 37 ± 10% (p < 0.001); ventricular arrhythmias decreased significantly after surgery. Factors influencing early mortality at multivariate analysis were the presence of critical fesions on the circumflex artery ana the duration of cardiopulmonary bypass. At 1-year control, a significant reduction in NYHA class was observed and no patient was in NYHA class IV. The improvement in ejection fraction was maintained (39 ± 11%), as well as the reduction in inducible and spontaneous ventricular arrhythmias. There were 5 late deaths at followup, accounting for a late mortality of 10% at 5 years.

Regional myocardial performance of non-ischaemic zones remote from anterior wall left ventricular aneurysm. Effects of aneurysmectomy.

The aim of this work was to investigate the effects of resecting a post-infarction left ventricular anterior aneurysm on the kinetics of the non-ischaemic inferior wall, remote from the healed lesion. Thirteen patients, with an anterior post-infarction aneurysm and a normal right coronary artery who underwent aneurysmectomy with endoventricular circular patch plasty reconstruction, had a complete haemodynamic study before and shortly after surgery. The shape of the left ventricle was quantitatively analysed by calculating the regional curvature at 90 points of the angiographic outlines (30 degrees right anterior oblique projection). Segmental wall motion was studied by means of the centreline method and by constructing pressure-length loops from the endocardial movement of 18 chords intersecting the left ventricular inferior contour and by simultaneously tracing the high-fidelity left ventricular pressure. Analysis of pressure-length regional loops showed a complex pattern of abnormal contraction and relaxation in the non-ischaemic inferior regions at baseline; after surgery such abnormalities decreased significantly and tended to revert to normal in many cases. Left ventricular shape in the inferior region was abnormal in 10/13 patients in that there was negative curvature at the interface between the aneurysm and the inferior wall that was corrected to positive after surgery. Regional inferior wall motion and global ejection fraction significantly improved after surgery in these 10 patients. The three patients whose global ejection fraction did not improve showed no inferior negative curvature pre-operatively, nor did they show an increase in inferior wall motion. The results indicate that regional function and shape in inferior, non-ischaemic regions, remote from an anterior aneurysm, are abnormal but potentially correctible if the abnormal mechanical burden imposed on the wall is relieved.

Systolic and diastolic function after patch reconstruction of left ventricular aneurysms

Left ventricular function after patch reconstruction for postinfarction left ventricular aneurysms is largely unknown. In this study, 16 patients with an anteroseptal-lateral left ventricular aneurysm were treated by reconstruction of the left ventricle using a Dacron patch. Coronary artery bypass grafting was performed concomitantly in 9 patients. The size of the patch used was 57% +/- 19% of the resected myocardial scar area, including the sewing cuff area to be sutured. In these patients, the ejection fraction increased significantly from 0.28 +/- 0.12 to 0.39 +/- 0.12 (p = 0.007) at rest and from 0.32 +/- 0.14 to 0.41 +/- 0.10 (p = 0.008) during exercise. The left ventricular end-diastolic pressure and left ventricular end-diastolic volume index were reduced significantly from 14 +/- 7.0 to 8 +/- 3.2 mm Hg (p = 0.032), and from 178 +/- 116 to 92 +/- 21 mL/m2 (p = 0.016). The peak filling rate was improved significantly from 1.2 +/- 0.47 to 1.8 +/- 0.6/s (p = 0.048) postoperatively. The ratio of the peak flow velocity during the atrial kick phase to the peak flow velocity in the rapid filling phase, at the level of the mitral valve, improved (p = 0.016) after operation and remained improved up to 16 to 24 months after operation. Patch reconstruction of the left ventricle resulted in the recovery of systolic and diastolic function soon after operation, which has persisted into the late postoperative period.

Left ventricular shape changes induced by aneurysmectomy with endoventricular circular patch plasty reconstruction.

Aneurysmectomy with left ventricular (LV) patch plasty reconstruction for anterior post-infarction LV aneurysm is usually followed by favourable haemodynamic results. The aim of this work was to describe the changes in LV shape induced by the intervention and to correlate them to the pre-operative data and to the surgical results. Twenty-two patients submitted to aneurysmectomy with this technique underwent a haemodynamic study before and 10-15 days after the intervention. Segmental wall motion was studied by the centreline method. LV shape was analysed by calculating the regional curvature of angiographic outlines (RAO 30 degrees projection). Results showed an improvement in LV pump function in 17 patients, which appeared mainly due to increased systolic shortening of the inferior wall. The intervention-induced modifications of LV geometry were characterized by: (1) marked reduction in end-diastolic volume, (2) shift of the angiographic apex counterclockwise, towards the aortic corner, (3) disappearance of the rim with negative curvature corresponding to the infero-apical border of the aneurysm, where the inferior wall resumed a normal outward convexity. No significant difference was found between the pre-operative haemodynamic data of patients who improved after surgery and those who did not. The presence of a rim of negative curvature at the infero-apical border of the aneurysm was the only pre-operative sign with a predictive value for the surgical outcome.

Results of nonguided subtotal endocardiectomy associated with left ventricular reconstruction in patients with ischemic ventricular arrhythmias

We analyzed the effects of nonguided endocardiectomy in patients with ischemic ventricular arrhythmias who underwent reconstructive operations for postinfarction left ventricular aneurysm. A total of 106 patients among 287 consecutive patients had spontaneous or inducible ventricular tachycardia (49 spontaneous and 57 inducible). Cryotherapy was done in 67 patients and coronary revascularization was done in 98%. Patients underwent complete hemodynamic study including programmed ventricular stimulation before and early after operation. Thirty-seven patients underwent hemodynamic evaluation after 1 year. The hospital mortality rate was 7.5%. At early and late studies the mean ejection fraction was significantly increased. Ventricular tachycardia was no longer inducible in 92% of patients after operation; only two patients had spontaneous ventricular tachycardia early after operation. At late study 10.8% of patients had inducible ventricular tachycardia and no spontaneous ventricular tachycardia was documented. All surviving patients had clinical follow-up (mean 21.3 months, range 2 to 64 months). There were eight late deaths and no episodes of ventricular tachycardia or syncope that necessitated hospitalization. In conclusion, nonguided, extended endocardiectomy associated with left ventricular reconstruction is safe and effective in curing ischemic spontaneous and inducible ventricular tachycardia.

Postinfarction left ventricular aneurysm and ventricular septal defect assessed by precordial and transesophageal echocardiography

Postinfarction left ventricular aneurysm and ventricular septal defect assessed by precordial and transesophageal echocardiography

Left ventricular aneurysm secondary to Behçet's disease

A 16-year-old boy with Behçet's disease who was seen with thrombophlebitis of the leg was found to have coronary artery occlusion with postinfarction left ventricular aneurysm. Recurrent femoral artery aneurysms and orogenital ulceration developed in him. The diagnostic features together with successful treatment of this patient and a discussion of Behçet's syndrome are presented.

Availability of111In-labeled platelet scintigraphy in patients with postinfarction left ventricular aneurysm

Eighteen patients with postinfarction left ventricular aneurysms (LVAs) were examined with Indium-111-labeled autologous platelet scintigraphy to identify intracardiac thrombi and to investigate the effect of antithrombotic agents on thrombogenesity within their LVAs. Left ventriculography (LVG), and two-dimensional echocardiography were also carried out to assess the diagnostic ability of the platelet imaging. Indium-111-platelet scintigraphy for the detection of LVA mural thrombi had a sensitivity of 60% and a specificity of 100%. Four of six patients with false-negative scintigraphic studies had been under antiplatelet therapy. Eight of the nine patients who had showed active platelet deposition on initial examination had not received antiplatelet therapy. Thereafter, five of these nine were treated with tichlopidine (300 mg/day) for 29.8 +/- 5.0 days. On the second platelet study, two had resolution and the other three had interruption of intra-aneurysmal deposition, which remained positive. In only one patient of the three, the third platelet study was performed after warfarin therapy. It took two weeks after beginning the therapy to completely interrupt platelet deposition within the LVA in this patient. ECG gated radionuclide ventriculography and Thallium-201-myocardial scintigraphy were also performed to assess left ventricular wall motion of left ventricular ejection fraction (LVEF) and myocardial blood perfusion. Thallium-201-SPECT showed apical or anteroapical perfusion defects and the radionuclide ventriculography correctly identified all 18 apical and anteroseptal aneurysms which were confirmed by LVG methods. The comparison between the thrombus positive group and the thrombus negative group was carried out on both the LVEF and the period from the last myocardial infarction to the initial platelet scanning study. There were no statistical differences in the LVEF and the interval (34.5 +/- 12.5% vs 37.3 +/- 14.6%, 39.6 +/- 52.6 days vs 89.6 +/- 108.3 days) between the two groups. These results suggest that Indium-111-labeled platelet scintigraphy can be a reliable method for the identification of active left ventricular mural thrombi and a practical method of judging antiplatelet and anticoagulant therapy.

Use of autologous pericardium for repair of left ventricular aneurysms

Two-hundred and ten patients with postinfarction left ventricular aneurysms underwent aneurysmectomy. In the first 80 patients we used Teflon felts and in the following 130 patients autologous pericardial strips were used for supporting the ventriculotomy site. In the first group, two patients developed false aneurysms and five developed infection in the postoperative period. In the second group, there were no such instances. The advantages of pericardium over artificial fabric are highlighted.

心筋梗塞後左室りゅうに対する外科療法の効果と限界

心筋梗塞後左室りゅうに対する外科療法の効果と限界

心筋梗塞後左室りゅうに対する外科治療

心筋梗塞後左室りゅうに対する外科治療

Left ventricular aneurysm with predominating congestive heart failure: A comparative study of medical and surgical treatment

From 1979 to 1985, 109 patients were treated for congestive heart failure caused by postinfarction left ventricular aneurysm. Congestive heart failure was predominant in all patients at the time of diagnosis, 73% of whom were in Functional Class III or IV. Left ventricular end-diastolic pressure averaged 23.8 +/- 0.8 mm Hg (mean +/- standard error of the mean), total ejection fraction 29.7% +/- 1.0%, and telediastolic volume of the aneurysm 76.2 +/- 5.8 ml. Aneurysmectomy was performed in 49 patients (45%), whereas the remaining 60 patients were treated medically. The two groups did not differ in regard to clinical and hemodynamic data on admission, except for a more extensive coronary artery disease in the surgical group. Follow-up was obtained for all patients (100%) and averaged 48 +/- 3 months. Actuarial survival curves were similar, and the 5-year survival rates for surgical and medical groups were 70 +/- 7% and 64% +/- 7%, respectively (not significant). However, the 5-year complication-free rate was significantly (p = 0.05) higher among surgical patients (52% +/- 8%) than among the medical group (31% +/- 7%). Multivariate analysis showed the following variables to influence survival independently (p less than 0.05): contractile segment ejection fraction, right ventricular failure, antecedents of cardiac arrest or cardiogenic shock, and corrected contractile score. Independent variables decreasing the risk of cardiac-related complications and death (p less than 0.05) were as follows: surgical treatment, shorter interval between initial infarction and diagnosis of aneurysm, and absence of right ventricular failure. Functional improvement was directly related to surgical treatment and to residual segment contractile score (p less than 0.05). Thus, in patients with congestive heart failure caused by left ventricular aneurysm, surgical treatment improved the quality of life and prognosis for cardiac-related complications, but did not increase overall survival, compared to medical management of similar patients.

Clinical improvement and long-term survival after surgical treatment of postinfarction left ventricular aneurysm.

Left ventricular aneurysmectomy was performed on 45 men and 12 women (mean age 57 years) during a 12-year period. The hospital mortality was 14% and the cumulative 5-year survival 57% +/- 9 (SE). Of 35 survivors, 33 underwent a follow-up study (mean 28 months post-operatively). The mean cardiothoracic index fell from 0.58 +/- 0.08 (SD) to 0.51 +/- 0.04 and the mean left ventricular ejection fraction (EF) improved from 0.30 +/- 0.08 to 0.38 +/- 0.01 (both changes significant). Echocardiographic parameters showed no significant improvement in left ventricular function. The NYHA classification was I or II in 85% of the patients at follow-up, but in only 23% preoperatively. Preoperative EF greater than or equal to 0.30 was associated with 76% +/- 16 (SE) cumulative 5-year survival as compared with 31% +/- 12 when EF had been less than 0.30. In view of these results, left ventricular aneurysmectomy should be recommended for all symptomatic patients.

Surgical Treatment of the Post-infarction Left Ventricular Aneurysm. Factors Influencing Early and Late Results

The early and late results of a 4 year surgical experience with 119 left ventricular aneurysms (LVA) are analyzed. The most common indication for surgery was angina in 78 patients, congestive heart failure (CHF) in 34, arrhythmia in 5 and recurrent embolism in 1. One patient was operated on prophylactically. There were 112 "anterior" and 7 "posterior" aneurysms. Preoperative ventricular function was significantly worse in the CHF group. LVA resection was carried out in 105 patients and a plicature in other 14. In 92 cases the procedure was combined with a myocardial revascularization. Additional cardiac procedures were performed in 14 patients. Overall early (5.9%) and late mortality (18.7%) was significantly higher in the CHF group than in the angina group (14.7% versus 1.3%, p less than 0.01, and 37.9% versus 12.9%, p less than 0.01, respectively). Associated surgical procedures (p less than 0.001) and acuity of the LVA (p less than 0.05) also increased the operative risk. The 5 year-survival was better for the angina group (85.7 +/- 4%) and arrhythmias group (80 +/- 22%) than for CHF patients (46.7 +/- 19%) (p = 0.052). Functional improvement was uniform between survivors of all groups (73.2%). In 15 patients with pre- and postoperative studies hemodynamic parameters were found improved although only a global contractile score did reach significant levels (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)