Left ventricular reconstruction: update to left ventricular aneurysm/reshaping techniques

Multislice computed tomography-guided surgical repair of acquired posterior left ventricular aneurysms: demonstration of mitral valve and left ventricular reverse remodelling

OBJECTIVES

Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms.

METHODS

Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD).

RESULTS

Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD.

CONCLUSIONS

MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms.

[Preoperative and follow-up cardiac magnetic resonance imaging of candidates for surgical ventricular restoration]

PURPOSE

To assess pre and post-operative cardiac MRI (CMR) findings in patients with left endoventriculoplasty repair for ventricular aneurysm due to ischemic heart disease.

MATERIAL AND METHODS

Data were retrospectively gathered on 21 patients with diagnosis of ventricular aneurysm secondary to ischemic heart disease undergoing left endoventriculoplasty repair between January 2007 and March 2013. Pre and post-operative CMR was performed in 12 patients. The following data were evaluated in pre-operative and post-operative CMR studies: quantitative analysis of left ventricular ejection fraction (LVEF), left ventricular end-diastolic (LVEDV) and end-systolic (LVESV) volume index, presence of valvular disease and intracardiac thrombi. The time between surgery and post-operative CRM studies was 3-24 months.

RESULTS

Significant differences were found in the pre and post-operative LVEF, LVEDV and LVESV data. EF showed a median increase of 10% (IQR 2-15) (p=0.003). The LVEDV showed a median decrease of 38 ml/m(2) (IQR 18-52) (p=0.006) and the LVESV showed a median decrease of 45 ml/m(2) (IQR:12-60) (p=0.008). Post-operative ventricular volume reduction was significantly higher in those patients with preoperative LVESV >110 ml/m(2) (59 ml/m(2) and 12 ml/m(2), p=0.006).

CONCLUSION

In patients with ischemic heart disease that are candidates for left endoventriculoplasty, CMR is a reliable non-invasive and reproducible technique for the evaluation of the scar before the surgery and the ventricular volumes and its evolution after endoventricular surgical repair.

Characterizing heart failure in the ventricular volume domain

Heart failure (HF) may be accompanied by considerable alterations of left ventricular (LV) volume, depending on the particular phenotype. Two major types of HF have been identified, although heterogeneity within each category may be considerable. All variants of HF show substantially elevated LV filling pressures, which tend to induce changes in LV size and shape. Yet, one type of HF is characterized by near-normal values for LV end-diastolic volume (EDV) and even a smaller end-systolic volume (ESV) than in matched groups of persons without cardiac disease. Furthermore, accumulating evidence indicates that, both in terms of shape and size, in men and women, the heart reacts differently to adaptive stimuli as well as to certain pharmacological interventions. Adjustments of ESV and EDV such as in HF patients are associated with (reverse) remodeling mechanisms. Therefore, it is logical to analyze HF subtypes in a graphical representation that relates ESV to EDV. Following this route, one may expect that the two major phenotypes of HF are identified as distinct entities localized in different areas of the LV volume domain. The precise coordinates of this position imply unique characteristics in terms of the actual operating point for LV volume regulation. Evidently, ejection fraction (EF; equal to 1 minus the ratio of ESV and EDV) carries little information within the LV volume representation. Thus far, classification of HF is based on information regarding EF combined with EDV. Our analysis shows that ESV in the two HF groups follows different patterns in dependency of EDV. This observation suggests that a superior HF classification system should primarily be founded on information embodied by ESV.

Congenital left ventricular outpouchings: a systematic review of 839 cases and introduction of a novel classification after two centuries

BACKGROUND

Congenital left ventricular outpouchings (LVOs) are reported under five overlapping and poorly defined terms including left ventricular accessory chamber, left ventricular aneurysm (LVA), left ventricular diverticulum (LVD), double-chambered LV, and accessory left ventricle. Diagnostic criteria are frequently mixed and not mutually exclusive. They convey no information regarding treatment strategy and prognosis.

OBJECTIVES

The aim of this systematic review is to provide a clear and inclusive classification, with therapeutic and prognostic implications, for congenital LVOs.

DATA SOURCES

We performed three separate sets of search on three subjects including "congenital left ventricular outpouchings," "important and simply measurable markers of left ventricular function," and "relationship of mechanics of intraventricular blood flow and optimal vortex formation in left ventricle and elliptical geometry of LV."

STUDY ELIGIBILITY CRITERIA

We enrolled case series, review articles, and case reports with literature review. All types of acquired LVO's were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

We studied the abstracts of all searched articles. We focused on diagnostic criteria and patients' outcome. To examine the validity and reliability of the novel classification, fifteen previous studies were revisited using the novel classification.

RESULTS

A total of 20 papers from 11 countries fulfilled our inclusion criteria. The age of patients ranged from prenatal age to geriatric age range. Diagnostic criteria were clearly stated only for two of the above five terms (i.e., congenital LVA and congenital LVD). Cases with mixed diagnostic criteria were frequent.Elliptical geometry of left ventricle was found to have significant impact on effective blood flow mechanics in LV. A simple inclusive classification for congenital LVOs, with therapeutic and prognostic implications, was introduced.

CONCLUSION

The cornerstone of this classification is elliptical LV geometry. Large-type IIc LVO have dismal prognosis, if left untreated. LVO type I and small LVO type IIa have the best prognosis.