Apical left ventricular aneurysm without atrio-ventricular block due to a lamin A/C gene mutation

BACKGROUND

Mutations in LMNA gene encoding two ubiquitously expressed nuclear proteins, lamins A and C, give rise to up to 7 different pathologies affecting specific tissues. Three of these disorders affect cardiac and/or skeletal muscles with atrio-ventricular conduction disturbances, dilated cardiomyopathy and sudden cardiac death as common features.

RESULTS

A new LMNA mutation (1621C>T, R541C) was found in two members of a French family with a history of ventricular rhythm disturbances and an uncommon form of systolic left ventricle dysfunction. The two patients: the proband and his daughter, were affected and exhibited an atypical form of dilated cardiomyopathy with an unexplained left ventricle aneurysm revealed by ventricular rhythm disturbances without atrio-ventricular block.

CONCLUSION

This finding reinforces the highly variable phenotypic expression of LMNA mutation and emphasizes the fact that LMNA mutations can be associated with different cardiac phenotypes.

[Left ventricular aneurysmectomy with geometric reconstruction]

OBJECTIVE

To summarize the experience in performing left ventricular aneurysmectomy (LVA) with geometric reconstruction and concomitant coronary artery bypass grafting (CABG) without mortality.

METHODS

Forty-two patients underwent LVA with geometric reconstruction and concomitant CABG. Forty-one patients were male, one was female with mean age of (55.5 +/- 2.4) years (40 - 68 years). Preoperative cardiac function was NYHA class III in 32 patients and class IV in 10. Thirty-eight patients had unstable angina pectoris and 10 had the history of severe ventricular arrythmia. Eight patients had ventricular tachycardia. Preoperative left ventricular ejection fraction (LVEF) was 41% (17% - 63%), LVEF was less than 40% in 29 cases. Left ventricular anatomic aneurysms were confirmed by ventriculography. Thirty-three cases underwent Jatene technique; 8 cases, Dor technique, and 1 case, Cooley technique. Mural thrombi were found in 21 patients and were completely removed. CABG was concomitantly performed in all patients. All of the left anterior descending artery was bypassed with left internal mammary artery and the other target vessels with saphenous vein. Mean cardiopulmonary bypass time was (135 +/- 11) minutes and aortic clamping time was (78 +/- 10) minutes.

RESULTS

No hospital mortality occurred and all patients were discharged. Postoperative reexploration for bleeding in 1 patient. The diameter and end systolic and diastolic volume of left ventricle were significantly decreased to nearly normal after operation. Operative ejection fraction had a tendency to increase but without significance (P > 0.05).

CONCLUSIONS

LVA with geometric reconstruction and concomitant CABG could not only improve heart function but also eliminate ventricular arrythmia. The clinical result was excellent.

Results of endoaneurysmorrhaphy: does the location of the aneurysm matter?

Endoaneurysmorrhaphy is mostly performed on anterior-septal left ventricular (LV) aneurysms. It may also be applied to posterior aneurysms, which is technically more challenging. Whether the surgical risk is the same, irrespective of the location of the aneurysm, has not been studied before. We reviewed our experience with 158 patients (62+/-9 years, 72% male) undergoing endoaneurysmorrhaphy. Eleven patients (7%) had posterior LV aneurysms. Perioperative mortality was 5.7%. Of all preoperative and surgical variables tested, the presence of a posterior LV aneurysm (p=0.017), concomitant mitral valve surgery (p=0.008) and duration of extracorporal circulation (p=0.001) were significantly associated with higher perioperative mortality. However, patients with posterior LV aneurysms had more severe heart failure (p=0.0061) and a higher LV end diastolic volume index (138+/-38 vs. 102+/-41 ml/kg body weight; p=0.040) than patients with antero-septal LV aneurysms. Further studies are needed to determine whether the location of the aneurysm is a risk factor for mortality irrespective of the clinical presentation.

Milking-like effect secondary to systolic expansion of a post-infarction left ventricular aneurysm

Systolic compression of coronary arteries is almost always due to the existence of myocardial bridging. We present a patient with a post-infarction left ventricular aneurysm in whom coronary angiography showed a milking-like effect with systolic compression of the distal left anterior descending coronary artery.

Improved left ventricular aneurysm repair with bioengineered vascular smooth muscle grafts

BACKGROUND

Recurrent ventricular dilatation can occur after surgical repair of a left ventricular (LV) aneurysm. Use of an autologous bioengineered muscle graft to replace resected scar tissue may prevent recurrent dilatation and improve cardiac function.

METHODS

Vascular smooth muscle cells (SMCs, 5 x 10(6) cells) from rat aortas were seeded onto synthetic PCLA (sponge polymer of epsilon-caprolactone-co-L-lactide reinforced with knitted poly-L-lactide fabric) patches and cultured for 2 weeks to allow tissue formation. Syngenic rats underwent proximal left coronary artery ligation to create a transmural myocardial scar. Four weeks after coronary ligation, cell-seeded patches (n=15) or unseeded patches (n=12) were used for a modified endoventricular circular patch plasty (EVCPP) repair of the infarct area. Ligated controls (n=14) and nonligated normal rats (n=10) had sham surgeries without EVCPP. Cardiac function was assessed by echocardiography and isolated Langendorff heart perfusion. Graft histology and morphology was also assessed.

RESULTS

After 8 weeks in vivo, seeded patches were thicker (P<0.05) and smaller in area (P<0.003) than unseeded patches. Only seeded patches had prominent elastic tissue formation (P<0.001) in association with SMCs. LV systolic function by echocardiography was improved in the seeded group compared with both unseeded (P<0.002) and control groups (P<0.0001). LV volumes in both patch repair groups were comparable but were significantly smaller (P<0.05) than controls. LV distensibility tended toward improvement in the seeded group as compared with unseeded hearts, but the difference did not achieve statistical significance (P=0.06).

CONCLUSIONS

Surgical repair with muscle-cell seeded grafts reduced abnormal chamber distensibility and improved LV function after myocardial infarction as compared with unseeded grafts. Bioengineered muscle grafts may be superior to synthetic materials for the surgical repair of LV scar.

Role of transesophageal echocardiography in the evaluation of patients with stroke

This review article summarizes recent advances in the care of patients presenting with neurologic events, in which transesophageal echocardiography plays an important role in diagnosis, prognosis, and treatment. New research on the use of transesophageal echocardiography in patients with stroke and atrial fibrillation is discussed, including left atrial clot formation, maintenance of sinus rhythm after cardioversion, and techniques of left atrial appendage occlusion. A discussion of developments in the diagnosis and management of thoracic aortic plaque follows. The association of patent foramen ovale and atrial septal aneurysm with stroke is outlined, and possible reasons for this association are discussed. Recent literature on the use of percutaneous closure devices for patent foramen ovale is reviewed.

Factors affecting late survival after surgical remodeling of left ventricular aneurysms

OBJECTIVES

Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods.

METHODS

From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch.

RESULTS

Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04).

CONCLUSIONS

Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.

Sustained cavity obliteration and apical aneurysm formation in apical hypertrophic cardiomyopathy

OBJECTIVES

In patients with apical hypertrophic cardiomyopathy (ApHCM), we estimated the severity of cavity obliteration (CO) in the apical potion of the left ventricle and correlated it with various clinical findings including apical aneurysm.

BACKGROUND

Apical hypertrophic cardiomyopathy sometimes develops apical aneurysm. The apical CO is often exhibited in ApHCM along with apical hypertrophy and ischemia. It remains unclear, however, how the CO and others are related to aneurysm.

METHODS

In 46 patients with ApHCM, we measured CO time on M-mode echocardiography and corrected it by the R-R interval (cCOT). We divided the 46 patients into the following groups: 17 with cCOT <or=200 ms (no/mild CO group); 18 with cCOT >200 to <or=350 ms (moderate CO group); and 11 with cCOT >350 ms (severe CO group). We then compared apical aneurysm, hypertrophy, ischemia, QT interval, and the like between the three groups.

RESULTS

The severe CO group exclusively comprised 11 patients having apical aneurysm and paradoxic jet flow. Of the 11 patients, 10 exhibited irreversible defects on exercise single photon emission computed tomography with thallium-201. All with moderate CO showed reversible defects, and none with no/mild CO showed any defects. Left ventricular hypertrophy and the corrected QT interval (QTc) were largest in the severe CO group. There were high correlations between the cCOT, hypertrophy, ischemia, and QTc. Of the 11 patients with severe CO, 6 had nonsustained ventricular tachycardia and 1 had mural thrombus.

CONCLUSIONS

In ApHCM, sustained CO is an important pathophysiologic condition as well as hypertrophy, ischemia, and prolonged QTc, which are considered jointly related to the development of aneurysm through interactions.

An underrecognized subepicardial reentrant ventricular tachycardia attributable to left ventricular aneurysm in patients with normal coronary arteriograms

BACKGROUND

In patients with apparently normal hearts, ventricular tachycardia (VT) may only involve the subepicardial myocardium.

METHODS AND RESULTS

Four patients with exercise-induced fast VT with right bundle branch block morphology were investigated. ECG showed a small q wave in leads II, III, and aVF during sinus rhythm (SR) in all 4 patients. Left ventricular angiography showed small inferolateral aneurysms in all patients. Coronary arteriograms were normal in all 4 patients. Six unstable VTs (cycle length, 200 to 305 ms) and 1 stable VT (cycle length 370 ms) were reproducibly induced in the 4 patients. During SR, endocardial mapping was normal in all 4 patients, and epicardial mapping showed fragmented and late potentials in the left inferolateral wall anatomically consistent with the left ventricle aneurysm. During tachycardia, epicardial mapping showed a macroreentrant VT with focal endocardial activation in the patient with stable VT, whereas in 2 patients with unstable VT, a diastolic potential was only recorded and coincided with the late potential in the same area. Epicardial ablation was performed in 3 patients and successfully abolished those VTs. No VT recurred in 2 patients during follow-up of 2 and 9 months. Clinical VT recurred 6 months after the ablation and was successfully ablated in a repeated epicardial ablation in 1 patient. In the remaining patient without epicardial ablation, an implantable cardiac defibrillator was implanted. There were multiple shocks during a follow-up of 31 months.

CONCLUSIONS

In patients with normal coronary arteriograms and left ventricle aneurysm, exercise-induced VT with right bundle branch block morphology may have a subepicardial arrhythmogenic substrate, which may be amenable to epicardial ablation.

[Comparison of early clinical results after left ventricular aneurysmectomy using classic and modified technique]

INTRODUCTION

In our department left ventricular aneurysmectomy was performed using only classic Cooley technique until 1989. Since then a modified technique was introduced: left ventricular geometry reconstruction modo Stoney simultaneously with the excision of scarred endocardium.

AIM

Comparison of early clinical results after left ventricular aneurysmectomy using classic (Group A) and modified technique (Group B).

MATERIAL AND METHODS

Retrospective data analysis of early clinical outcome of patients (pts) operated from 1989 to 2000: classic technique 74 pts [63M (85.1%); 11F (14.9%); average age 52.26 +/- 10.35 years], modified technique 86 pts [74M (86%); 12F (14%); average age 55.83 +/- 9.3].

RESULTS

No statistically significant differences between groups considering number of critically stenosed coronary arteries, left ventricular ejection fraction and left ventricular diameters were observed. Mean number of bypass grafts (gr. A 1.55, gr. B 1.69); aortic crossclamping time (gr. A 48.1 (24-77) +/- 12.9; gr. B 50.9 (0-91) +/- 16.1) were not significantly different between groups. In gr. A, 11 (14.8%) pts died: low output syndrome (LOS) 3 pts, LOS and ventricular dysrhythmias (VD) 5 pts, VD 3 pts. In gr. B 4 (4.6%) pts died: LOS 3 pts; LOS and VD 1 pt. Among other complications LOS and VD occurred significantly more frequently in gr. A. In both groups average postoperative ejection fraction increased; twice higher in gr. B than A.

CONCLUSIONS

Modified technique: 1. Significantly decreases incidence of ventricular dysrhythmias in comparison to classic technique. 2. Significantly lowers incidence of low output syndrome and mortality rates in comparison to classic technique.

MRI evaluation of left ventricular function in anterior LV aneurysms before and after surgical resection

OBJECTIVES

Whether resection of a left ventricular (LV) aneurysm leads to improved global LV function remains controversial. Echo-planar magnetic resonance imaging (MRI) is a sensitive tool to detect changes in LV function. Therefore, the purpose of the present study was to monitor changes in global LV function and anatomy following LV aneurysm resection using MRI.

METHODS

The present study includes 12 patients with an anterior LV aneurysm. Echo-planar MRI evaluation of LV function was performed before surgery and 6 weeks and 3 months after LV remodeling surgery, in most patients combined with coronary artery by-pass grafting (CABG).

RESULTS

Following LV aneurysm resection, a decrease was found in end-diastolic volume from 238+/-63 to 180+/-54 ml at 6 weeks to 198+/-51 ml (P<0.05) at 3 months and in end-systolic volume from 156+/-62 to 105+/-44 to 111+/-43 ml (P<0.01), whereas the ejection fraction increased from 37+/-11 to 43+/-9 to 45+/-10% (P<0.01).

CONCLUSIONS

LV remodeling surgery leads to a cardiac anatomy more closely resembling normal anatomy. As a consequence, LV contractile function improved significantly. In addition, it was shown that echo-planar cardiac MRI is a sensitive tool to study subtle changes in heart anatomy and function. In this preliminary experience, pre- and postoperative MRI has demonstrated that LV remodeling surgery may restore cardiac anatomy and improve LV contractile function.

[Left ventricular aneurysms: principles of surgical treatment]

After reviewing the historical background, the morphology and physiopathology of left ventricular aneurysms, the authors review the physiology, the technical aspects, and the current surgical indications of aneurysmectomy, with a particular emphasis on the concept of endoventriculoplasty of Jatène & Dor.

[Assessment of left ventricular ejection fraction and wall motion in patients after myocardial infarction with and without persistent electrocardiographic ST-segment elevation--using gated radionuclide angiography]

In everyday practice two-dimensional echocardiography is a routine method used to diagnose left ventricular (LV) wall motion abnormalities and determine ejection fraction (EF). However, in some patients, for technical reasons, it is possible to apply only apical projections and EF and LV wall motion abnormalities cannot be therefore obtained. The aim of the study was to measure LV EF and wall motion abnormalities in the patients healed from MI, with and without persistent electrocardiographic ST segment elevation, in whom echocardiographic diagnosis was difficult. LV wall motion abnormalities and EF were determined using non-invasive method--gated radionuclide angiography. Gated radionuclide angiography was performed in 45 patients, 3 months after previous anterior MI. The study was acquired after technetium 99mTc red cell labeling in vivo. The data were collected using a Toshiba scintillation gamma camera with a MODUMED computer system coupled with a gating device. Patients were divided into two groups. Group I consisted of 24 patients with persistent electrocardiographic ST segment elevation and group II--of 21 patients without persistent elevation of this segment.

RESULTS

In the group I, left ventricular ejection fraction ranged between 10 and 36% (mean: 24%). In 9/24 patients (38%) diffuse hypokinesis, in 7/24 patients (29%) regional akinesis and in the last 8/24 patients (33%) regional dyskinesis with impaired dilated left ventricular systolic and diastolic function were observed. In the group II, left ventricular ejection fraction ranged from 19 to 47%. Mean value of this parameter equaled 32% and was statistically significantly higher than in patients from group II. In 9/21 patients (42%) diffuse hypokinesis, in 2/21 patients (10%) regional anterior wall hypokinesis with the normal function of other walls, and in the last 10/21 patients (48%) regional anterior wall akinesis with the diffuse hypokinesis of other walls were localized. In the patients without persistent electrocardiographic ST segment elevation, diffuse hypokinesis was observed in majority of cases. In none of those patients ventricular aneurysm was diagnosed. In the patients with persistent electrocardiographic ST segment elevation, three types of decreased left ventricular function (diffuse hypokinesis, regional akinesis and ventricular aneurysm) were observed. It should be noted that in 1/3 of those patients ventricular aneurysm was diagnosed. Presence of diskinetic wall motion abnormalities in group I (in 8/24 patients) was statistically significantly more frequent (p < 0.01) than in group II (in 0/21 patients).

CONCLUSIONS

1. Presence of persistent electrocardiographic ST segment elevation in a patient with post infarction myocardial failure is a prerequisite for suspicion of post myocardial infarction left-ventricular aneurysm. 2. In patients without persistent electrocardiographic ST segment elevation and post infarction myocardial failure diffuse hipokinesis (sometimes with regional akinesis) is predominantly observed.

Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction

OBJECTIVES

We examined the relationship among biventricular hemodynamics, pulmonary regurgitant fraction (PRF), right ventricular outflow tract (RVOT) aneurysm or akinesia, and baseline and surgical characteristics in adults with repaired tetralogy of Fallot (rTOF).

BACKGROUND

The precise relationship of pulmonary regurgitation with biventricular hemodynamics has been hampered by limitations of right ventricular (RV) imaging.

METHODS

We assessed 85 consecutive adults with rTOF and 26 matched healthy controls using cardiovascular magnetic resonance imaging.

RESULTS

Patients had higher right ventricular end-diastolic volume index (RVEDVi) (p < 0.001), right ventricular end-systolic volume index (RVESVi) (p < 0.001), right ventricular mass index (RVMi) (p < 0.001), and lower right ventricular ejection fraction (RVEF) (p < 0.001) and left ventricular ejection fraction (LVEF) (p = 0.002) compared to controls. The PRF (range 0% to 55%) independently predicted RVEDVi (p < 0.01) and the latter predicted RVESVi (p < 0.01) and RVMi (p < 0.01). The RVOT aneurysm/akinesia was present in 48/85 (56.9%) of patients and predicted RV volumes (RVEDVi, p = 0.01, and RVESVi, p = 0.03). There was a negative effect of RVOT aneurysm/akinesia and RVMi on RVEF (p < 0.01 and p = 0.02, respectively). There was only a tendency among patients with transannular or RVOT patching toward RVOT aneurysm/akinesia (p = 0.09). The LVEF correlated with RVEF (r = 0.67, p < 0.001).

CONCLUSIONS

Pulmonary regurgitation and RVOT aneurysm/akinesia were independently associated with RV dilation and the latter with RV hypertrophy late after rTOF. The RVOT aneurysm/akinesia was common but related only in part to RVOT or transannular patching. Both RV hypertrophy and RVOT aneurysm/akinesia were associated with lower RVEF. Left ventricular systolic dysfunction correlated with RV dysfunction, suggesting an unfavorable ventricular-ventricular interaction. Measures to maintain or restore pulmonary valve function and avoid RVOT aneurysm/akinesia are mandatory for preserving biventricular function late after rTOF.

Biomechanical modeling of hemodynamic factors determining bulging of ventricular aneurysms

BACKGROUND

Ventricular aneurysm formation is a frequent complication of transmural myocardial infarction. The hemodynamic determinants of aneurysmal bulging remain unclear.

METHODS

A rubber heart placed in a water tank served as an in vitro model. Rhythmic injections of specific volumes into the tank simulated heart beats. The heart rate was adjustable in increments. A section of the heart model's wall was shielded from compression to simulate an aneurysm. To quantitate the relation between hemodynamics and bulging, pressures, echocardiographic measurements of maximal expansion, and mean velocity were recorded. Bulging volume, stroke volume, aneurysmal wall stress, and systemic resistance were calculated.

RESULTS

The mean velocity was the echocardiographic factor most closely related to bulging volume (r = 0.92, p < 0.01). When bulging indices were compared with hemodynamics, bulging volume and mean velocity were found to directly depend on heart rate (r = 0.66, p < 0.01; r = 0.70, p < 0.01). Polynomial regression revealed bulging volume to reach minimal values near 80 beats/min. Maximal systolic aneurysmal wall stress was closely related to the peak positive rate of pressure change (r = 0.94, p < 0.01) and moderately to stroke volume (r = 0.75, p < 0.01). Filling pressures were unrelated to bulging. The greatest bulging volume reduction occurred below 790 dynes x s x cm(-5); bulging was practically eliminated at systemic resistance values less than 395 dynes x s x cm(-5).

CONCLUSIONS

Aneurysmal bulging and aneurysm formation depend mainly on heart rate, contractility, and afterload. This suggests that hemodynamic management may affect the extent of bulging in a clinical setting.