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Surgery for correction of anterior left ventricular aneurysm.

Almeida R.M.S.S.A., Lima Jr. J.D., Bastos L.C., Flores E.Q, Loures D.

Serviço de Cirurgia Cardiovascular - Instituto de Moléstias Cardiovasculares de Cascavel.
Hospital Policlínica de Cascavel. Cascavel. Paraná. BRASIL.

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Abstract
Introduction
Objectives
Material and Methods
Results
Discussion
Conclusions

Abstract

Objetive: To show the peri-operative, medium and long-term results, of the left ventricular (LV) aneurysm surgical resection, due to ischemic disease.
Patients and methods: Between July of 1992 and June of 1999, 1400 cardiac surgeries were performed. Of the aorto-coronary artery bypass group of 436 patients, 12,8% were submitted to surgical resection of their anterior left ventricular aneurysms’, due to ischemic disease. Mean age was 57,1 years, being 67,8% men. There was a clinical history or electrocardiographic alterations, of myocardial infarction (MI), in 52 patients; in 16,1% MI was less than 30 days. The principal cause for surgical treatment was congestive heart failure, in 37 cases, class III or IV (NYHA), followed by angina in 17 cases and arrhythmia in two. Moderate to severe left ventricular dysfunction was present in 30 patients. Left ventricular mural thrombus were present in 26 patients, and from this group 2 had previous embolic cerebral stokes. In 54 cases the surgical approach for left ventricular aneurysm correction was the linear closure technique; in two recent cases, the Dor's approach was used in patients with severe left ventricular dysfunction. Aorta-coronary artery by-pass grafting was additionally performed in 51 patients, and in 37 cases the coronary grafted, was the one responsible for the MI. A total of 104 grafts were performed.
Results: The hospital mortality was 1,8%. The intra-aortic balloon pump was used in three cases. In the late post-operative period six patients were study angiografically and found to have patent grafts and normal left ventricular function. Twelve patients had a 2-D Echo, post-operatively that showed improvement in L.V. function, including the resected area.
Conclusions: It is possible to perform repair of the left ventricle aneurysms' with a low incidence of morbidity or mortality, and that patients benefit from concomitant coronary artery by-pass, to the infarcted area.

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Introduction:

Left ventricular aneurysm (LVA) is a complication of transmural infarction, defined as a portion of the left ventricle, that becomes thin and dilated, with distinct margins, and that leads to an akinetic scar or a dyskinetic aneurysm, during the ventricular contraction. Described by John Hunter, in the XVIII century, only in 1881, was the relationship between this identity and coronary disease established. The diagnostic was made angiographically, after 1951, and before only by X-Rays. In 1944, Beck et. al, reinforced with "fascia-lata" a LVA, but it was not until 1954, that Likoff and Bailey, started the new era of closed resection of LVA. The concept of the functional and morphological benefits produced by an open ressection, were suggested by Cooley, in 1958. From them on many surgeons made their contributions to the surgical treatment of LVA. In 1973, Stoney, suggested the "overcoat" plicature, in 977, Dagget described the posterior patch and in 1979, Levitsky, the anterior one; in 1980 Hutchkins and Brawley, published the first paper with reports on the influence of cardiac geometry of the left ventricle (LV) and it's geometric reconstruction. Based on these evidences new techniques developed like the Jatene's circular reduction and geometrical reconstruction (1984), Dor's endoventricular patch-septal exclusion (1985), Cooley's endoaneurysmorraphy (1989) and Mickleborough's tailored scar incision (1994). All these techniques of LVA surgical therapy showed us that the right way was towards a LV reconstruction.

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Objectives:

The objective of these presentation is to show the peri-operative, medium and long-term results of LVA, due to ischemi disease, surgical resection, by the linear closure technique and our trend to LV surgical reconstruction with the Dor's technique.

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Material and Methods:

Between july 1992 and june 1999, 1400 cardiac surgeries were performed, at the department of cardiovascular surgery of the "Instituto de Moléstias Cardiovasculares de Cascavel". From this group 436 patients had myocardial revascularization (MR), and 12,6%, of this group, were submitted to a surgical resection of their anterior LVA alone or in association with MR, all performed by one surgeon (RMSA). The mean age, of the 55 patients, was 59,2 years, with a range of 28 to 72 years, and 65,5% were male. Forty eight patients (87,3%) had a clinical history of congestive heart failure, class III or IV (NYHA), being in 36 cases the only indication, forty (72,7%) of angina, being in 17 cases the only indication, and two (3,6%) of arrhythmia. Fifty two patients (95,5%) had a clinical history of myocardial infarction, or compatible electrocardiographic alterations. The population's mean weight was 71 kg, height 165 cm and body surface 180 cm2. Of this group 40% had concomitant chronic obstructive pulmonary disease, 18,2% were diabetic and 1,8% had renal insufficiency. The indication for LVA surgical therapy was elective in 46 cases (81,8%), urgent in five (9,1%) and an emergency in another five cases. All patients underwent preoperative hemodynamic, cinecoronary studies and LV ventriculography. In 5 (9.1%) only one coronary artery was diseased, apart from the left anterior descending (LAD) artery, in 20 (36,4%) a double vessel disease was observed and in 13 (23,6%) three or mores vessels were diseased. The LAD was occluded in all patients, with collateral circulation in 35 (63,6%). Of these group the LAD was the only vessel occluded in 17 (30,9%). All patients presented with dyskenitic anterior LV (46%) or akinetic anterior LV (24%). Left ventricular mural thrombus were present in 23 (41,8%) patients. In two cases there was a history of previous cerebral embolic strokes, with no major consequences. The operative technique for all procedures was a standard median sternotomy. The patient was placed on by-pass using a cavo-atrial cannula through the right atrium and an arterial line cannulating the ascending aorta. The myocardial protection was achieved with moderate hypothermia (28-32ºC) and St. Thomas cold cardioplegia at 4ºC infused in the aortic root and repeated every 30 minutes. After identification of the LVA a ventriculotomy was performed and, the clots removed if present. In the great majority of cases a double linear suture was the method of choice for closure of the LVA. Recently we started to use Dor's endoventriculoplasty technique, in two. The total by-pass time was, in media, 72,6 min (26-129 min) and the cross clamp time was 32,2 min (11-84 min). When LVA was performed alone the mean by-pass time was 32,6 min and the mean cross-clamp time 15 min; if LVA was performed with one by-pass graft, the times were 55,1 min and 24,5 min, if it was with two by-passes, 78 min and 35,5 min, if with three 101,7 min and 48,2 min and with four 116 min and 57,3 min respectively. Fifty patients had concomitant coronary arteries by-passed, with 105 conduits (2,1 grafts/patient), which were all performed after the completion of the surgical correction of the LVA. Arterial conduits were used in 30 cases (54,5%) as the only conduit or with another arterial conduit and vein grafts in the other cases. Revascularization with grafts to the LAD coronary system was achieved in 50 cases (52,4%), being in 35 (63,6%) cases to the LAD it self. The right coronary artery territory was grafted in 23 cases (21,9%) and the circumflex in 24 (22,8%) cases. Endarterectomy was performed in two cases, both to the LAD. Inotropic support, defined by a high dose of catecolamines for more than 24 hours, was required in four patients (7,3%) and intra-aortic balloon counterpulsation in two ( 3,6%) cases, performed by a new technique, with a mean time of ventricular assistance of 52,8 hours. The mean hospital stay time was 10,5 days; only one patient required more than 15 days in hospital, due to pulmonary complications (22 days).

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Results:

There were no deaths, related the operation or the post-operative period. The 30 day hospital mortality was 1,8%. One patient, a severe diabetic women (200 cm2 of body surface), died on the 13th post-op. day due to a mediastinitis, which was treated with by means of a continuos infusion of betadine and systemic antibiotics. One patient was reoperated for bleeding, on the same operative day. All patients were discharged on NYHA I or II. One patient died on the 6th post-operative month, due to respiratory infection. The two patients in which the Dor's endoventricular patch-septal exclusion technique was used had an ejection fraction of 28 and 46%, which improved to 45 and 60% respectively, after 30 days.

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Discussion:

Our series is similar to those of the international literature, except by the high incidence of LVA in our population that had MR. This is probably because invasive interventions used in the management of myocardial infarction, such us thrombolytic therapy and coronary angioplasty, in the acute phase of myocardial infarction, are seldom performed due to the late arrival of these patients to our institution. When a diagnosis is made, surgical treatment is performed, depending on the patients' symptoms, because of the fewer symptoms that these patients experience, the improvement in the quality of life and the longer life expectancy. The involvement of other coronary arteries seems to be increasing, and a complete MR, was a goal, together with the LVA surgical treatment. Due to the fact that grafting the LAD, there is a possibility of increasing septal perfusion, and that this fact will decrease the cases of right ventricular failure, we have increase the number of patients, in which a deceased LAD is revascularized. The trans or post operative complications were not related to the cardiopulmonary by-pass or aortic cross-clamp time, but to the poor LV function. At the start of our experience, the linear technique of suturing an aneurismatic area, seemed an ideal technique due to two factors: the easy reproduction and the shorter time of cross-clamping and by-pass. But there was the disadvantage of not recovering the original shape of the left ventricle, and with it diminishing its stroke volume and contraction. Following Jatene's and Dor's publications, we started to enrol the LVA that had a greater dyskinetic area or a akinetic scar to a endoventriculoplasty technique. From our two first cases the mean improvement of ejection fraction was 15,5% (from 37% to 52,5%). In the beginning of our experience with the Dor's technique the cardio-pulmonary by-pass time was higher than in same group with linear LV suture. The hospital mortality, in this series was 1,8%, which is less than that published in the literature, and occurred in a patient with concomitant MR, in which we had used homologous vein grafts. The long-term survival was 98,2%, and the only death occurred on a patient with severe respiratory problems, and had no relation to the surgical procedure. Five of the 53 survivors were recatheterised, in a period of 7 days to 15 months, and the cath data compared with the pre-op. one. The left ventricle function improved 10%, and of the 14 grafts, only one was occluded (7,1%).

Conclusions:

The authors conclude that is possible to perform surgical correction of LVA, with low mortality, even when associated with MR, which should be as complete, as possible, including the occluded LAD coronary artery.

 

Questions, contributions and commentaries to the Authors: send an e-mail message (up to 15 lines, without attachments) to surgery-pcvc@pcvc.sminter.com.ar , written either in English, Spanish, or Portuguese.

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Bioengineering
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Update
Nov/11/1999