Left Ventricular Aneurysm Repair Research Articles

Endoventricular remodeling of left ventricular aneurysm. Functional, clinical, and electrophysiological results.

Recent advances in surgical techniques for the repair of left ventricular aneurysms (LVAs) include the use of an endoventricular patch to exclude the aneurysm cavity. This technique has replaced conventional linear plication of the aneurysm. The endoventricular patch technique remodels the left ventricular cavity to a more physiological geometry that improves function. From December 1989 through November 1993, 45 patients underwent an LVA repair with an endoventricular patch. This procedure was performed in association with coronary artery bypass grafting in 40 patients. Twenty-eight patients (62.2%) also had nonguided encircling subendocardial incisions. Operative procedures included 7 emergency operations, 3 concomitant valve procedures, and a mean of 2.2 bypass grafts per patient. Eight patients had previous cardiac operations. Hospital mortality was 15.6% (7/45) for all patients and 9.1% (3/33) for nonemergent revascularization and LVA repairs. Ejection fraction improved from a mean of 25.8% preoperatively to 37.8% postoperatively; the mean New York Heart Association classification improved from 3.5 to 1.5. Of patients known to have preoperative arrhythmias (inducible or sudden death), 69% were not inducible postoperatively without antiarrhythmic medication. Survival from late cardiac death (including death of unknown origin) was 86.5% at 2 years. Freedom from documented ventricular arrhythmias was 94.3% at 2 years. These results indicate that the patch endoaneurysmorrhaphy technique can provide an excellent functional and physiological outcome in patients with LVAs and severely impaired ventricular function.

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/m 2 and end-systolic volume index from 77 ±45 to 53 ±25 ml/m 2 , 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, χ 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. ( J Thorac Cardiovasc Surg 1995;110:1291-301)

Thoracotomy for repair of left ventricular aneurysm in a patient with patent coronary bypass grafts

A 72-year-old man presented with a posterior left ventricular aneurysm 5 years after undergoing quadruple coronary artery bypass grafting. An angiogram demonstrated patent saphenous vein grafts, but also showed incidental asymptomatic aortic aneurysms. Left ventricular endoaneurysmorrhaphy was performed through a left thoracotomy. This approach affords excellent exposure of a posterior left ventricular aneurysm, averts many of the risks associated with reoperation, and should be considered in patients who have undergone a median sternotomy and who do not require myocardial revascularization.

Risk and benefit of low systemic heparinization during open heart operations

Heparin surface-coated perfusion equipment with improved thromboresistance was evaluated in 104 consecutive patients undergoing open heart operation in a prospective, randomized trial with low versus full systemic heparinization. Surgical procedures included coronary artery revascularization in 47 of 54 (87%) for low versus 44 of 50 patients (88%; not significant [NS]) for full, valve repair/replacement in 8 of 54 (15%) for low versus 5 of 50 patients (10%; NS) for full, left ventricular aneurysm repair in 1 of 54 (2%) for low versus 2 of 50 patients (4%; NS) for full, and other in 3 of 54 (6%) for low versus 3 of 50 patients (6%; NS) for full. Cross-clamp time was 39.2 ± 10.7 minutes for low versus 39.5 ± 10.5 minutes for full (NS). Cardiopulmonary bypass time was 68.6 ± 20.1 minutes for low versus 69.3 ± 16.6 minutes for full (NS). Lowest activated coagulation time during perfusion was 255 ± 75 seconds for low versus 537 ± 205 seconds for full ( p < 0.0005). In the low group, the target activated coagulation time of more than 180 seconds was not reached during perfusion in 4 of 54 patients (7%), the lowest value being 164 seconds. No oxygenator failure occurred. Hospital mortality was 0 of 54 (0%) for low versus 1 of 50 patients (2%) for full (NS). Bleeding required surgical revision in 0 of 54 (0%) for low versus 4 of 50 patients (8%) for full ( p = 0.05). Drainage (24 hours) was 790 ± 393 mL for low versus 1,039 ± 732 mL for full ( p < 0.025). Amount of packed homologous red cells transfused (24 hours) was 300 ± 354 mL for low versus 957 ± 596 mL for full ( p < 0.0005). Baseline hematocrit of 43.3% ± 3.7% for low versus 43.0% ± 3.9% (NS) for full before operation moved to 28.9% ± 3.2% for low versus 28.8% ± 3.2% for full (NS) at 24 hours. Low systemic heparinization during open heart operation results in reduced blood loss and transfusion requirements.

Pericardial patch repair of left ventricular aneurysm

Infectious complications associated with the use of Teflon felt buttresses in left ventricular aneurysm repair may result in serious morbidity. Use of an autologous pericardial patch is an alternative approach that should be considered. The technique, which we have used in 4 patients, is described.

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 preoperative 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.

Late follow-up after repair of left ventricular aneurysm and (usually) associated coronary bypass grafting

This study assesses clinical and operative data on a large group of patients in whom a left ventricular (LV) aneurysm was repaired to determine factors that might predict in-hospital and long-term outcome. Long-term follow-up study was obtained in 296 of 298 patients undergoing LV aneurysm repair with or without coronary artery bypass grafting between 1974 and 1986. No patient had sustained a myocardial infarction within 2 weeks of surgery or was undergoing other concurrent cardiac surgery. The average age of the study patients was 57 ± 9 years and the average ejection fraction was 35 ± 13%. Ninety percent of the patients underwent concurrent bypass grafting, with an average of 2.2 ± 1.3 grafts placed. Fourteen (5%) patients died in the hospital, with most deaths attributable to LV dysfunction. Advanced age and less extensive revascularization were correlates of inhospital mortality. The 10-year survival was 57%, myocardial infarction-free survival 43%, and freedom from death, myocardial infarction and reoperative coronary surgery 41%. Advanced age, systemic hypertension, significant left main coronary artery narrowing and emergent operative status were multivariate correlates of long-term mortality. A low-risk population was defined by the absence of these risk factors, and high-risk by the presence of ≥1 risk factors. The 10-year survival was 71% in the low-risk and 41% in the high-risk groups (p = .0006). The 10-year myocardial infarction free survival was 55% in the low-risk and 31% in the high-risk groups (p = 0.0017). LV aneurysm repair may be performed with acceptable in-hospital mortality, and the long-term risk may be stratified. However, in the absence of controlled studies, uncertainty remains as to the appropriate patients for LV aneurysm repair.

Repair of posterior left ventricular aneurysm in a six-year-old boy

Left ventricular aneurysms and diverticula are rarely encountered in the pediatric age group. This paper reports a case of congestive heart failure and mitral regurgitation in a 6-year-old boy with a large posterolateral left ventricular aneurysm. Complete repair was successfully performed by excision of the aneurysm and Dacron patch reconstruction of the left ventricular free wall. The patch extended onto the posterior annulus of the mitral valve, thus restoring the mitral valve to normal geometry and correcting the mitral insufficiency. The surgical literature on congenital cardiac diverticula and acquired aneurysms in children is reviewed and summarized.

Simulated left ventricular aneurysm and aneurysm repair in swine

Patch reconstruction of left ventricular aneurysm may be superior to linear closure, but this hypothesis has not been tested experimentally. Accordingly, six anesthetized domestic pigs were instrumented to measure regional left ventricular wall thickening, stroke volume, systolic left ventricular pressure, and myocardial oxygen consumption. With total bypass and cardioplegia, a 6 by 8 cm Dacron patch was inserted into the anteroapical left ventricle. Simulations were as follows: left ventricular aneurysm, patch open; patch reconstruction, 50% patch plication; standard repair, ventriculotomy edges approximated. Global function, from stroke work (stroke volume x integral of left ventricular pressure)-left ventricular end-diastolic pressure curves, was depressed in all three simulations compared with control. A tendency for stroke work to be greater for standard repair than for left ventricular aneurysm and patch reconstruction at higher preloads was not statistically significant. Mechanical efficiency, from stroke work/myocardial oxygen consumption (joules per milliliter oxygen per beat), was 2.43 +/- 0.52 (mean +/- standard error of the mean) (control), 2.22 +/- 0.94 (standard repair), 1.27 +/- 0.39 (patch reconstruction), and 1.09 +/- 0.37 (left ventricular aneurysm) (no significant differences). Regional work was calculated as regional left ventricular wall thickening x integral of left ventricular pressure. The slope of the regional work-end-diastolic wall thickness relation decreased in the posterior wall 14.0 +/- 2.9 (control) versus 8.4 +/- 2.0 (left ventricular aneurysm), 6.9 +/- 1.4 (patch reconstruction), and 7.4 +/- 1.4 (standard repair) (p less than 0.05). In the anterior wall, contractility did not change significantly (7.4 +/- 1.2, control; 7.8 +/- 2.7, left ventricular aneurysm; 5.0 +/- 0.4, patch reconstruction; and 5.3 +/- 0.4, standard repair). Decreased end-diastolic wall thinning anteriorly suggested tethering. These results in the normal left ventricle suggest that patch ventriculoplasty is of no greater benefit than linear repair. Either repair may impede function of adjacent myocardium through restriction of regional diastolic lengthening.

Successful Repair of Left Ventricular Aneurysm Associated with Mitral Regurgitation Secondary to Spasm-Induced Myocardial Infarction—A Case Report

A sixty-four-year-old man was admitted with a severe feeling of chest oppres sion and loss of consciousness. An echocardiogram and a left ventriculogram revealed a left ventricular aneurysm with severe mitral regurgitation, and a selective coronary angiogram demonstrated normal coronary arteries. Spasm- induced posterior myocardial infarction was diagnosed, and the patient under went combined left ventricular aneurysmectomy and mitral valve replacement. Six years after the surgery the patient remains well, without angina or heart failure.

Ten year followup of left ventricular aneurysm repair

Ten year followup of left ventricular aneurysm repair

Left Ventricular Aneurysm Repair with Myocardial Revascularization: An Analysis of 246 Consecutive Patients over 15 Years

From 1970 to 1985, 246 consecutive patients with left ventricular (LV) aneurysm underwent repair and concomitant myocardial revascularization at Ochsner Foundation Hospital. The overall incidence of perioperative death was 7.3%. Although the deaths were mainly cardiac related (10/18) with congestive heart failure (CHF) as the leading cause (6/10), 8 deaths were of noncardiac origin. Perioperative mortality increased significantly in patients with mitral regurgitation (MR) (22%; p = 0.0008); perioperative mortality for patients without MR was 4.8%. The overall 5-year survival was 69%. Late deaths were caused most commonly by myocardial infarction (20/32) with only 7 due to CHF. Predictors of long-term survival were related to LV function preoperatively: absence of CHF ( p = 0.001); LV end-diastolic pressure less than or equal to 20 mm Hg ( p = 0.03); and ejection fraction greater than or equal to 35% ( p = 0.02). Factors that did not significantly affect long-term survival were type of aneurysm repair (resection or plication), morphology of left anterior descending coronary artery (occlusion or stenosis), and size of the aneurysm.

Functional cardiac assessment before and after left ventricular anterior aneurysm repair, especially as related to work capacity.

Clinical, angiographic and hemodynamic parameters were assessed preoperatively and 12-20 weeks (mean +/- SD: 14 +/- 2) after left ventricular anterior aneurysmectomy in 31 consecutive patients. In 18 patients, associated coronary artery bypass surgery was necessary (1.4 grafts/patient). One patient with mitral valve insufficiency postoperatively required mitral valve replacement. No other complications and no deaths arose. The working capacity of the patients, as measured by bicycle exercise testing, compared a stage of exercise that the patient reached to the expected level of exercise for a normal person of the same sex, age and body surface. Expressed as percent of normals it increased from 39.3 +/- 28.9% (mean +/- SD) to 60.8 +/- 15.5% (p less than 0.001), angina-pectoris-free working capacity increased from 52.6 +/- 41.4 to 89.2 +/- 33.2 W (p less than 0.001). Left ventricular end-diastolic volume was determined by simultaneous biplane angiography and decreased from 277.1 +/- 84.7 to 191.0 +/- 49.1 ml (p less than 0.001). Ejection fraction increased from 35.4 +/- 12.4 to 41.0 +/- 9.6% (p less than 0.05). Left ventricular end-diastolic pressure after angiography decreased from 24.6 +/- 9.2 to 21.1 +/- 11.3 mm Hg (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Submitral left ventricular aneurysms: Correction by a new transatrial approach

Submitral left ventricular aneurysm is a widely recognized but relatively unknown entity that occurs almost exclusively in African patients and is often associated with mitral regurgitation. In the past 2 1/2 years, nine patients with submitral aneurysm were operated on by a new transatrial approach that exposes the neck of the aneurysm through an incision in the floor of the left atrium (roof of the aneurysm). There were four female and five male patients and the mean age was 28 +/- 3 years (range 23 to 35 years). All patients but one had significant mitral valve regurgitation and were in New York Heart Association Class III or IV. All operations were performed with standard cardiopulmonary bypass. At operation the neck of the aneurysm was invariably found beneath the posterior mitral valve anulus, at any site between the anterolateral and posteromedial commissures. The transverse diameter was variable, replacing up to two thirds of this portion of the annulus. In one patient the aneurysm perforated into the left atrial cavity. The neck of the aneurysm was closed directly in all patients and all mitral valves were preserved. Comprehensive valvuloplasty, including a Carpentier ring, was required in four patients. One patient died on the operating table of an uncontrolled diffuse pericardial hemorrhage. The remainder were discharged from the hospital and have good mitral valve function postoperatively. The transatrial approach to the repair of submitral left ventricular aneurysms results in a lower operative mortality and morbidity and almost invariably permits conservation of the mitral valve.

Clinical improvement after ventricular aneurysm repair: Prediction by angiographic and hemodynamic variables

Surgical repair of a left ventricular aneurysm is associated with significant perioperative mortality and substantial mortality in the first 2 years after operation. In a retrospective review of 42 patients undergoing repair of an anteroapical aneurysm, two cardiac catheterization variables were identified that predicted a good surgical outcome, defined as perioperative survival and improved functional status. Specifically, patients with an ejection fraction of the contractile section (nonaneurysmal) of the left ventricle of 35% or greater and a left ventricular end-diastolic pressure of 25 mm Hg or less had a low perioperative mortality rate (6.5%), experienced no late mortality and had sustained clinical improvement of at least one New York Heart Association functional class (93.5%). In contrast, patients with a contractile section ejection fraction of less than 35% or a left ventricular end-diastolic pressure greater than 25 mm Hg had a higher perioperative mortality rate (27.3%), experienced a substantial late mortality rate (27.3%) or had no significant functional class improvement (9%); only 36.4% had sustained clinical improvement. This study suggests that the postoperative results of left ventricular aneurysm repair are dependent on the hemodynamic status of the nonresected left ventricle.

Results of combined left ventricular aneurysmectomy and coronary artery bypass: 1974 to 1980

Left ventricular aneurysm repair with coronary artery bypass grafting was performed in 104 patients from 1974 through 1980. The patients' mean age was 57 years. Preoperatively, 48 percent were in New York Heart Association functional class III and 31 percent were in class IV. Stenosis of multiple vessels was common, as was a reduced ejection fraction (24 percent had an ejection fraction of less than 30 percent) Thrombus was present in 47 percent of resected aneurysms. Bypass grafting was performed to all graftable coronary vessels. Actuarial survival rates were 89.3 percent at 1 year, 86.1 percent at 2 years, and 74.5 percent (standard error 5.1 percent) at 5 years. One year postoperatively, 86 percent of the surviving patients were in class I, 11 percent class II, 1 percent class III, and 2 percent class IV. Patients who presented with angina alone had an excellent result, with 96 percent hospital survival. Congestive heart failure was an ominous finding, since four of five patients who developed it before discharge died in the hospital, and 38 percent of those who went into heart failure after discharge have died.

Right ventricular failure after repair of left ventricular aneurysm

This report summarizes the experience in two patients who have manifested severe right ventricular (RV) failure after resection of large left ventricular (LV) aneurysms involving the ventricular septum. In the first patient, early postoperative right atrial (RA) mean pressure (14 mm Hg) was similar to the mean pulmonary artery (PA) pressure (16 mm Hg) and exceeded left atrial (LA) pressure (10 mm Hg). A right-to-left shunt through a patent foramen ovale allowed adequate cardiac output at the expense of arterial desaturation. As RV function slowly improved, LA pressure exceeded RA pressure, pulmonary artery pulse pressure increased, and the shunt disappeared as the foramen ovale closed. In the second patient, initial attempts to wean from cardiopulmonary bypass with catecholamines and intra-aortic balloon pump were unsuccessful because of RV failure. RA pressure was 30 mm Hg and LA pressure was 12 mm Hg with a balloon-augmented peak arterial pressure of only 80 mm Hg. A ventricular assist pump (RA to PA) was used to wean the patient from bypass and resulted in adequate LA pressure (17 mm Hg), low RA pressure (6 mm Hg), and adequate cardiac index (1.9 L/min/m 2 ). On the operative and first postoperative day, there was no pulse pressure generated from RV contraction and all PA pulse pressure (40115 mm Hg) was due to the assist pump. Beginning on postoperative day 2, the RV generated increasing PA pulse pressures. The patient was weaned from the RV assist device, which was removed on postoperative day 3; then the PA pressure was 36/18 mm Hg, RA pressure 16 mm Hg, and LA pressure 18 mm Hg. Both patients remain well. These case histories would indicate that the lack of septal motion may not be a contraindication to repair of LV aneurysm as has previously been suggested; however, in such patients, the possibility of RV failure would make the availability of an assist pump advisable. Recovery of RV function can be expected within a few days.

Repair of ventricular septal defect and left ventricular aneurysm following myocardial infarction.

A successful simultaneous surgical repair of rupture of the interventricular septum and left ventricular aneurysm resulting from myocardial infarction is described. Very few similar cases have been described in the literature and in none was angiocardiography performed before operation. Preoperative angiocardiographic examination to demonstrate a ventricular aneurysm is of major importance in all cases of rupture of the interventricular septum following myocardial infarction. The right heart approach with injection of contrast material into the main pulmonary artery is shown to be the method of choice for this purpose.

Successful repair of left ventricular aneurysm due to trauma

A left ventricular aneurysm developed in a 17-year-old boy following severe nonpenetrating chest trauma. Successful surgical repair with cardiopulmonary bypass was performed six weeks after injury.

Successful Repair of Left Ventricular Aneurysm Due to Trauma

A left ventricular aneurysm developed in a 17-year-old boy following severe nonpenetrating chest trauma. Successful surgical repair with cardiopulmonary bypass was performed six weeks after injury.