Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm

State-of-the-Art Review: Technical and Imaging Considerations in Hybrid Transcatheter and Minimally Invasive Left Ventricular Reconstruction for Ischemic Heart Failure

Negative left ventricular (LV) remodeling consequent to acute myocardial infarction (AMI) is characterized by an increase in LV volumes in the presence of a depressed LVEF. In order to restore the shape, size, and function of the LV, operative treatment options to achieve volume reduction and shape reconstruction should be considered. In the past decade, conventional surgical LV reconstruction through a full median sternotomy has evolved towards a hybrid transcatheter and less invasive LV reconstruction. In order to perform a safe and effective hybrid LV reconstruction, thorough knowledge of the technical considerations and adequate use of multimodality imaging both pre- and intraoperatively are fundamental. In addition, a comprehensive understanding of the individual procedural steps from both a cardiological and surgical point of view is required.

A historical appraisal of the techniques of left ventricular volume reduction in ischemic cardiomyopathy: Who did what?

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

Left Ventricular Reconstruction Surgery in Candidates for Heart Transplantation

Objective

To report our center’s experience in the surgical treatment of ventricular reconstruction, an effective and efficient technique that allows patients with end-stage heart failure of ischemic etiology to have clinical improvement and increased survival.

Methods

Observational, clinical-surgical, sequential, retrospective study. Patients with ischemic cardiomyopathy and left ventricular aneurysm were attended at the Heart Failure, Ventricular Dysfunction and Cardiac Transplant outpatient clinic of the Dante Pazzanese Cardiology Institute, from January 2010 to December 2016. Data from 34 patients were collected, including systemic arterial hypertension, ejection fraction, New York Heart Association (NYHA) functional classification (FC), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II value, Society of Thoracic Surgeons (STS) score, ventricular reconstruction technique, and survival.

Results

Overall mortality of 14.7%, with hospital admission being 8.82% and late death being 5.88%. Total survival rate at five years of 85.3%. In the preoperative phase, NYHA FC was Class I in five patients, II in 18, III in eight, and IV in three vs. NYHA FC Class I in 17 patients, II in eight, III in six, and IV in three, in the postoperative period. EuroSCORE II mean value was 6.29, P≤0.01; hazard ratio (HR) 1.16 (95% confidence interval [CI] 1.02-1.31). STS mortality/morbidity score mean value was 18.14, P≤0.004; HR 1.19 (95% CI 1.05-1.33). Surgical techniques showed no difference in survival among Dor 81% vs. Jatene 91.7%.

Conclusion

Surgical treatment of left ventricular reconstruction in candidates for heart transplantation is effective, efficient, and safe, providing adequate survival.

Left Ventricular Aneurysm Repair: Off-pump Linear Plication versus On-pump Patch Plasty

Objective

The study aimed to compare the clinical outcomes of simplified linear plication and classic patch plasty in patients with left ventricular aneurysm (LVA).

Methods

We retrospectively reviewed 282 patients undergoing LVA repair between 2006 and 2016. After propensity score matching, 45 pairs of patients receiving LVA surgery were divided into either a patch group (on-pump endoventricular patch plasty) or a plication group (off-pump linear plication). Then, their early surgical outcomes and long-term survival were compared in two matched groups.

Results

The heart function improvement at discharge was similar in the two matched groups, while patients in the patch group more commonly suffered from low cardiac output syndrome (P=0.042) with higher proportion of intra-aortic balloon pumping assistance (P=0.034) than patients in the plication group. Compared with patients in the patch group, the patients in the plication group had shorter recovery times, regarding to mechanical ventilation, intensive care unit stay, and hospital stay (P<0.001, P<0.001, and P=0.001, respectively). No significant difference was found in the long-term survival (P=0.62).

Conclusions

Off-pump linear plication presented acceptable results in terms of early outcomes and long-term survival. For high-risk patients, the simplified LVA repair technique may be an option.

Heart Failure Interventions Targeting Impaired Left Ventricles in Structural Heart Disease

PURPOSE OF REVIEW

Interventional techniques have been developed for a wide spectrum of mechanisms of heart failure (HF), especially in valvular heart disease and cardiomyopathies (ischaemic cardiomyopathy and hypertrophic cardiomyopathy). In this article, we review recent reports on catheter interventions to treat patients with HF.

RECENT FINDINGS

Direct modification using the Parachute device and the REVIVENT-TC device for patients with impaired left ventricle with large infarct scars improves geometry and haemodynamic efficiency, resulting in a reduction of HF symptoms. Interatrial shunt therapy improves symptoms and quality of life in HF patients. Uniquely, left ventricular outflow tract obstruction has also been targeted in patients with transcatheter mitral valve implantation. For advanced stage HF patients with prohibitively high surgical risk, emerging transcatheter interventions make it possible to modify life-limiting symptoms. Further results on HF interventions are expected from ongoing clinical trials.

Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques

Different surgical techniques, each with its own advantages and disadvantages, have been used to reverse adverse left ventricular remodeling due to postinfarction left ventricular aneurysm. The most appropriate surgical technique depends on the location and size of the aneurysm and the scarred tissue, the patient's preoperative characteristics, and surgeon preference. This review covers the reconstructive surgical techniques for postinfarction left ventricular aneurysm.

Gastrointestinal Bleed from a Left Ventricle to Colonic Interposition Graft Fistula following an Esophagectomy

Colonic interposition grafts are commonly used as an esophageal conduit following esophageal resection. Significant morbidity is associated with this reconstruction due to the nature of the operation. Many of the complications associated with this procedure have clear management strategies; however, there is a paucity of data when it comes to managing rare complications. In this report, we discuss the presentation, operative intervention, and postoperative care of a patient who presented with a left ventricle to esophageal colonic interposition graft fistula.

Effects of Surgical Ventricular Restoration on Left Ventricular Shape, Size, and Function for Left Ventricular Anterior Aneurysm

Background:

Surgical ventricular restoration (SVR) has been performed to treat left ventricular (LV) aneurysm. However, there is limited analysis of changes in LV shape. This study aimed to evaluate the changes in LV shape induced by SVR and the effects of SVR on LV size and function for LV aneurysm.

Methods:

Between April 2006 and March 2015, 18 patients with dyskinetic (dyskinetic group) and 12 patients with akinetic (akinetic group) postinfarction LV anterior aneurysm receiving SVR with the Dor procedure at Chinese People's Liberation Army General Hospital were enrolled in this study. A retrospective analysis was carried out using data from the echocardiography database. LV shape was analyzed by calculating the apical conicity index (ACI). LV end-diastolic volume index, end-systolic volume index, and ejection fraction (EF) were measured. One-way analysis of variance was used to compare means at different time points within each group.

Results:

Within one week after SVR, LV shape became more conical in the two groups (ACI decreased from 0.84 ± 0.13 to 0.69 ± 0.11 [t = 5.155, P = 0.000] in dyskinetic group and from 0.73 ± 0.07 to 0.60 ± 0.11 [t = 2.701, P = 0.026] in akinetic group; LV volumes were decreased significantly and became closer to normal values and EF was improved significantly in the two groups). On follow-up at least one year, LV shape remained unchanged in dyskinetic group (ACI increased from 0.69 ± 0.11 to 0.74 ± 0.12, t = −1.109, P = 0.294), but became more spherical in akinetic group (ACI significantly increased from 0.60 ± 0.11 to 0.75 ± 0.11, t = −1.880, P = 0.047); LV volumes remained unchanged in dyskinetic group, but increased significantly in akinetic group and EF remained unchanged in the two groups.

Conclusions:

SVR could reshape LV to a more conical shape and a more normal size and improve LV function significantly early after the procedure in patients with dyskinetic or akinetic postinfarction LV anterior aneurysm. However, LV tends to be more spherical and enlarged in the akinetic group on at least 1-year follow-up.

The Effects of Levosimendan and Sodium Nitroprusside Combination on Left Ventricular Functions After Surgical Ventricular Reconstruction in Coronary Artery Bypass Grafting Patients

OBJECTIVE

The aim of our study was to research the effects of levosimendan (LS) and sodium nitroprusside (SNP) combination on systolic and diastolic ventricular function after coronary artery bypass grafting (CABG) who required endoventricular patch repair (EVPR).

PATIENTS AND METHODS

We studied 70 patients with ischemic dilated cardiomyopathy. LS and SNP combination was administered in 35 patients (study group, SG). In the remaining patients, normal saline solution was given (placebo group, PG). Levosimendan (10µgr/kg) started 4 h prior to operation and we stopped LS before the initiation of extracorporeal circulation (ECC). During the rewarming period, we started again levosimendan (10µgr/kg) in combination with SNP (0.1-0.2 µgr/kg/min). If mean blood pressure decreased by more than 25% compared with pre-infusion values, for corrected of mean arterial pressure, the volume loading was performed using a 500 ml ringer lactate. Hemodynamic variables, inotrophyc requirement, and laboratory values were recorded.

RESULTS

Five patients died (7.14%) post-surgery (one from SG and 4 from PG) due to low cardiac out-put syndrome (LOS). At the postoperative period, cardiac output and stroke volume index was higher in SG (mean±sd;29.1±6.3 vs. 18.4±4.9 mL/min(-1)/m(-2) (P<0.0001)). Stroke volume index (SVI) decreased from 29±10mL/m(2) preoperatively to 22±14mL/m(2) in the early postoperative period in group 1. This difference was statistically significant (P=0.002). Cardiac index was higher in SG (320.7±37.5 vs. 283.0±83.9 mL/min(-1)/m-(2) (P=0.009)). The postoperative inotrophyc requirement was less in SG (5.6±2.7 vs. 10.4±2.0 mg/kg, P< 0.008), and postoperative cardiac enzyme levels were less in SG (P< 0.01). Ten patients (28.5%) in SG and 21 patients (60%) in PG required inotrophyc support (P<0.001). We used IABP in eight patients (22.8%) in SG and 17 patients (48.5%) in CG (P=0.0001).

CONCLUSION

This study showed that LS and SNP combination impressive increase in left ventricular systolic and diastolic functions including LVEF. The use of this combination achieved more less inotrophics and IABP requirement. We therefore suggest preoperative and peroperative levosimendan and SNP combination.

Left Ventricular Aneurysmectomy: Tailored Scar Excision and Linear Closure

Coronary artery bypass surgery with or without aneurysmectomy is used to treat patients with left ventricular aneurysm. There is debate about patient selection and the appropriate surgical technique. We analyzed the results of 102 consecutive patients who underwent left ventricular aneurysmectomy and reconstruction using a modified linear closure technique between 1992 and 2003. The mean age was 62 years, 81% of the patients were male, and 47% had an ejection fraction < 35%. The locations of the left ventricular aneurysms were anteroapical (75%), apical (21%), and posteroinferior (4%); 23% contained thrombi. Additional procedures included aortic valve replacement in 4, mitral valve repair in 1, and coronary bypass grafting in 98 patients; 3 underwent isolated repair of left ventricular aneurysm. Hospital mortality was 7% and long-term survival was 76% at a mean follow-up of 39 months. Most patients improved symptomatically postoperatively. Left ventricular aneurysm repair with tailored scar excision and a modified closure technique is associated with acceptable mortality and long-term survival.

Left ventricular aneurysm repair with use of a bovine pericardial patch

Left ventricular aneurysm, which can impair systolic function, has a reported incidence of 10% to 35% in patients after myocardial infarction. In a 58-year-old woman who had a history of myocardial infarction, we excised a large left ventricular aneurysm and restored left ventricular geometry with use of a bovine pericardial patch. The aneurysm's characteristics and the patient's preoperative left ventricular ejection fraction of 0.25 had indicated surgical intervention. The patient had an uneventful postoperative course, and her left ventricular ejection fraction was 0.50 to 0.55 on the 4th postoperative day. This case illustrates the value of surgical treatment for patients who have a debilitating left ventricular aneurysm.

Left-ventricular aneurysms: from disease to repair

Myocardial infarction may be complicated by the formation of a left-ventricular aneurysm that distorts the normal elliptical geometry of the ventricle to produce a dilated spherical ventricle with limited contractile and filling capacities. One of the consequences is congestive heart failure, which may be refractory to medical therapy and require surgical treatment. Surgical methods to restore the volume and shape of the left ventricle have evolved over the years. Nevertheless, although surgery for left-ventricular aneurysms has been performed for almost 50 years, the most appropriate approach is still controversial. This review gives an overview of the postinfarction left-ventricular aneurysm, tackling issues from the disease itself to surgical and other techniques of ventricular remodeling.

Quality of Life after 114 Months of Follow-up following Geometric Reconstruction of the Left Ventricle by Endoventriculoplasty with Septal Exclusion

Background: The purpose of this study was to present the surgical experience of the Institute of Cardiovascular Surgery of West of Paran (ICCOP) with respect to the treatment of left ventricle aneurysms by endoventriculoplasty with septal exclusion (EVSE) and to evaluate the quality of life of these patients after a 114-month follow-up.Methods: Between April 1999 and April 2006, 28 patients underwent EVSE. Preoperative, transoperative, and late postoperative clinical and echocardiographic variables were analyzed retrospectively. In addition, latepostoperative quality of life was evaluated with questionnaire SF-36 (Brazilian version). The mean age (SD) of the group was 59.0 9.5 years, and 23 of the patients were male. Seventeen patients were in New York Heart Association functional class IV, and the mean preoperative EuroSCORE was 8.2 2.3. The mean preoperative values for the ejection fraction (EF) and the end-systolic and end-diastolic left ventricular volumes were 32.3% 9.2%, 113.9 36.0 mL, and 179.2 48.4 mL, respectively.Results: The in-hospital mortality rate was 14.3%, with the major causes of morbidity being low cardiac output syndrome and arrhythmias. The mean follow-up period was 5.9 3.4 years. The left ventricular EF and the aortic cross-clamping time were the significant factors for hospital and late mortality (P = .0222, and P = .0123, respectively). The actuarial survival curve showed survival rates of 82.1 7.2%, and 54.7 22.9%, before and after 107 months of follow-up. The overall score for the quality of life showed an improvement.Conclusion: EVSE surgery is an effective option for treating this group of patients, with improvement noted in left ventricular function and in the patients' quality of life, despite the high in-hospital mortality.

Long-term outcomes after surgical ventricular restoration and coronary artery bypass grafting in patients with postinfarction left ventricular anterior aneurysm

OBJECTIVE

Surgical ventricular restoration (SVR) for postinfarction left ventricular anterior aneurysm improves left ventricular function. The aim of this study was to evaluate whether concomitant multivessel coronary artery disease (MVCAD) can affect long-term outcome. Thus, long-term results of SVR associated with multiple coronary artery bypass grafting (CABG) for MVCAD (group 1) were compared with SVR with or without CABG to left anterior descending artery and/or its diagonal branch for single-vessel coronary artery disease (group 2).

METHODS

Data from 104 consecutive patients (age 64 +/- 8 years) with left ventricular anterior aneurysm, subjected to SVR from January 1994 to December 2004 and divided into group 1 (n = 79) and group 2 (n = 25), were analyzed.

RESULTS

In group 1 vs. group 2, number of grafts/patient (2.7 +/- 0.9 vs. 0.6 +/- 0.6, P < 0.0001) was higher, cardiopulmonary bypass (109 +/- 30 vs. 65 +/- 28 min, P < 0.0001) and aortic cross-clamp times (65 +/- 18 vs. 44 +/- 23 min, P < 0.0001) were longer, resected aneurysmatic area (12 +/- 8 vs. 17 +/- 11 cm2, P < 0.05) was smaller. Operative mortality was 3.7 vs. 4% (P = not significant). At 12 years, survival (85 +/- 5 vs. 80 +/- 16%) and freedom from cardiac events (70 +/- 7 vs. 75 +/- 16%) were not statistically different in both groups. Follow-up echocardiography showed significant left ventricular ejection fraction improvement in group 1 (0.45 +/- 0.07 vs. 0.34 +/- 0.10 preoperatively, P < 0.0001) and group 2 (0.47 +/- 0.09 vs. 0.36 +/- 0.12, P = 0.001). Independent predictors of late death were preoperative history of ventricular arrhythmias (P < 0.001) and hypo/akinesia of proximal myocardial anterior wall (P < 0.05).

CONCLUSION

Late survival and freedom from cardiac events are excellent after SVR, also when concomitant MVCAD requires complete revascularization. Ventricular arrhythmias and impaired left ventricular anterior wall function are predictors of worse outcome.

Left ventricular aneurysm repair: a comparison of linear versus patch remodeling

BACKGROUND

Surgical repair of left ventricular (LV) aneurysm has been performed for around 50 years. However, the most appropriate surgical approach remains undetermined. This study was undertaken to compare the efficacy of 2 established techniques, linear versus patch remodeling, for repair of dyskinetic LV aneurysms.

METHODS

We retrospectively reviewed the records of 49 patients (mean age, 69.8 +/- 7.3 years) who had operation for postinfarction dyskinetic LV aneurysm between 1996 and 2006. Thirty-one patients underwent patch remodeling and 18 underwent linear repair. Short-term and mid-term outcomes, including complications, cardiac function and mortality, were assessed.

RESULTS

Overall inhospital surgical mortality, major complications and early hemodynamics showed no significant differences between the 2 groups. During a mean follow-up of 44.0 +/- 34.4 months, 8 patients died, with 4 due to cardiac-related causes. Actuarial survival rates at 1, 5 and 10 years were 85.7%, 69.9% and 45.7%, respectively. Functional class improved from 2.51 +/- 0.59 to 1.66 +/- 0.54 among the mid-term survivors (p < 0.001), with no significant difference between the 2 groups. Multivariate analysis identified preoperative NYHA functional class >or= 3 as an independent risk factor for overall mortality (p = 0.008). Mid-term follow-up revealed that LV ejection fraction improved from 26.5 +/- 7.2% to 34.1 +/- 7.9% (p < 0.001) in the patch group, and from 26.3 +/- 9.0% to 32.0 +/- 9.2% in the linear group (p = 0.032). In contrast, right ventricular ejection fraction improved from 49.4 +/- 10.1% to 52.0 +/- 7.3% (p = 0.190) in the patch group, but deteriorated from 55.0 +/- 6.3% to 50.3 +/- 8.6% in the linear group (p = 0.029).

CONCLUSION

These findings indicate that the 2 repair techniques have similar effectiveness with respect to short- and mid-term outcomes except for right ventricular ejection fraction. We suggest that the selection of repair technique for LV aneurysms should be individualized for each patient based on aneurysm size and extent of the scarring process into the septum and subvalvular mitral apparatus.

Surgery for left ventricular aneurysm: is there still any role for simple linear repair?

The aim of left ventricular aneurysm (LVA) surgery is to eliminate the diskinetic portion of the left ventricle and to restore the patient's clinical condition. This can be obtained with two surgical procedures: linear repair and endoventricular patch technique. We investigated early- and long-term results in patients who underwent both procedures. From January 1980 to December 2004, 158 patients underwent surgical repair of LVA: 86 had linear repair and 72 patch repair. Operative mortality was 6.9%, with no differences between the two groups. Logistic regression revealed older age, higher left ventricular end-diastolic volume, and an ejection fraction (EF) less than 30% as independent risk factors for in-hospital mortality; the type of operation "per se" did not influence the early mortality. At the follow-up extending up to 25 years, there was no statistically significant difference in survival between the two study groups, as well as in New York Heart Association and Canadian Cardiovascular Society classes. Cox regression revealed older age, EF less than 30%, urgent operation, and a history of cerebrovascular accident as independent risk factors for late mortality: the type of operation did not influence mortality at follow-up. We conclude that aneurysm resection associated with myocardial revascularization is the best treatment for LVA. The choice of the technique should be tailored on an individual basis, according to aneurism location, extension, residual ventricular function, and septal involvement.

Left Ventricular Reconstruction by Modified Linear Technique with Absorbable Suture

BACKGROUND

Linear and endoventricular techniques of left ventricular (LV) reconstruction often utilise prosthetic material for epicardial reinforcement or endocardial patch. We report a technique of LV aneurysm repair using absorbable suture without prosthetic material.

METHODS

Between November 1999 and August 2004, 55 patients underwent linear LV reconstruction, for ischaemic cardiomyopathy, using only continuous 3/0 polydioxanone suture. Survival, functional class and echocardiographic outcomes are reported.

RESULTS

Fifty-two patients (mean age 64+/-10 years) were studied. There was no perioperative mortality and the Kaplan-Meier survival at five years was 81%. Fifty-one patients underwent postoperative follow up (mean 28 months) with echocardiography (mean 20 months). There were no recurrent aneurysms. The postoperative LV eccentricity index (EI) was 0.72 (CI 0.48-0.9). Mean LV ejection fraction increased from 0.33+/-0.09 preoperatively to 0.41+/-0.15 at late follow up (mean within patient change 0.08+/-0.15, p=0.003). Mean symptom class improved from 3.3+/-0.8 to 1.6+/-0.7 (mean within patient improvement 1.6+/-1.0, p<0.001). Mitral regurgitation of grade 2/4 was identified in six patients and grade 3/4 in one patient.

CONCLUSION

Linear repair with absorbable suture material and without prosthetic material may be safely undertaken with good early and mid-term results.

Left ventricular restoration: how important is the surgical treatment of ischemic heart failure trial?

If the Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrates that surgical therapy is superior to medical therapy, early aggressive evaluation of coronary artery disease as a potentially correctable cause of new-onset heart failure would be the preferred strategy. This strategy could tremendously change the treatment of ischemic heart disease. Confirming the STICH revascularization hypothesis will dramatically increase the use of coronary artery bypass grafting among the millions of patients now being medically treated without evaluation for an ischemic cause.

Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration

OBJECTIVES

Our objectives were (1) to report operative and long-term mortality in patients submitted to anterior surgical ventricular restoration, (2) to report changes in clinical and cardiac status induced by surgical ventricular restoration, and (3) to report predictors of death in a large cohort of patients operated on at San Donato Hospital, Milan, Italy.

METHODS

A total of 1161 consecutive patients (83% men, 62 +/- 10 years) had anterior surgical ventricular restoration with or without coronary artery bypass grafting and with or without mitral repair/replacement. A complete echocardiographic study was performed in 488 of 1161 patients operated on between January 1998 and October 2005 (study group). The indication for surgery was heart failure in 60% of patients, angina, and/or a combination of the two.

RESULTS

Thirty-day cardiac mortality was 4.7% (55/1161) in the overall group and 4.9% (24/488) in the study group. Determinants of hospital mortality were mitral valve regurgitation and need for a mitral valve repair/replacement. Mitral regurgitation (>2+) associated with a New York Heart Association class greater than II and with diastolic dysfunction (early-to-late diastolic filling pressure >2) further increases mortality risk. Global systolic function improved postoperatively: ejection fraction improved from 33% +/- 9% to 40% +/- 10% (P < .001); end-diastolic and end-systolic volumes decreased from 211 +/- 73 to 142 +/- 50 and 145 +/- 64 to 88 +/- 40 mL, respectively (P < .001) early after surgery. New York Heart Association functional class improved from 2.7 +/- 0.9 to 1.6 +/- 0.7 (P < .001) late after surgery. Long-term survival in the overall population was 63% at 120 months.

CONCLUSIONS

Surgical ventricular restoration for ischemic heart failure reduces ventricular volumes, improves cardiac function and functional status, carries an acceptable operative mortality, and results in good long-term survival. Predictors of operative mortality are mitral regurgitation of 2+ or more, New York Heart Association class greater than II, and diastolic dysfunction (early-to-late diastolic filling pressure >2).

Reversing Left Ventricular Remodeling in Chronic Heart Failure

Chronic heart failure (CHF) has become an epidemic in the United States, with approximately 550,000 new cases annually. With the evolution of pharmacotherapy targeting neurohormonal pathways, the annual mortality in subjects with New York Heart Association (NYHA) class IV CHF has dramatically improved from 52% in the seminal CONSENSUS trial to less than 20% in more recent trials. Suppression of the renin-angiotensin-aldosterone system remains the first line of neurohormonal blockade followed by the addition of selective beta-adrenoreceptor blockers. For patients with NYHA class I and II symptoms, mortality rates have decreased to approximately 5% or less per year with the use of angiotensin-converting enzyme inhibitors, beta-blockers and aldosterone receptor blockers. However, after achieving optimal doses of the indicated pharmacotherapy, and despite the additional benefits obtained with biventricular pacemakers, there are still many patients who continue to experience signs and symptoms of CHF. Recognizing the beneficial effects of the above treatments on left ventricular (LV) remodeling, strategies have been developed to surgically reshape the left ventricle in patients with LV dilation who have associated poor LV function. This review will discuss the techniques and recent developments regarding surgical reshaping of the dilated, dysfunctional, and remodeled left ventricle.

Delayed Left Ventricular Pseudoaneurysms After Left Ventricular Aneurysm Repairs With the CorRestore Patch

We present two cases of left ventricular pseudoaneurysm that developed after left ventricular aneurysm repair with the CorRestore patch (Somanetics Corp, Troy, MI). Both patients underwent subsequent pseudoaneurysm repair with Dacron patches (Boston Scientific Corp, Natick, MA). We discuss the physiologic limitations of the CorRestore patch and the causes of pseudoaneurysms that arise after left ventricular aneurysm repair.

Surgery of left ventricular aneurysm: a meta-analysis of early outcomes following different reconstruction techniques

BACKGROUND

The purpose of this study is to assess the effects of linear and geometric left ventricular aneurysm reconstruction on early postoperative outcomes.

METHODS

A search of computerized databases supplemented with manual bibliographic review was performed for all peer-reviewed English language publications concerning randomized and nonrandomized studies reporting the results of left ventricular reconstruction after both linear and geometric reconstruction techniques. Meta-analyses of several short-term outcomes were performed.

RESULTS

No randomized trial was identified. Eighteen nonrandomized trials were found with a total of 1,814 and 803 patients who underwent linear and geometric reconstruction, respectively. Meta-analysis of all studies (n = 18) revealed an increased risk of in-hospital death for patients undergoing linear reconstruction (relative risk = 1.59, 95% confidence interval: 1.12 to 2.26, p = 0.01). The subanalysis of studies in which linear reconstruction was adopted mainly in the first period of time, and geometric reconstruction was adopted in a later phase, still showed a significant advantage in terms of in-hospital mortality for patients undergoing geometric reconstruction (n = 11 studies, relative risk = 1.89, 95% confidence interval: 1.22 to 2.93, p = 0.004). By contrast, when the two surgical approaches were carried out in the same time lag, there was no difference between linear and geometric reconstruction techniques (n = 7 studies, relative risk = 1.04, 95% confidence interval: 0.57 to 1.92, p = 0.89). No differences in the other outcomes of interest were observed.

CONCLUSIONS

The advantage for geometric reconstruction techniques in terms of in-hospital mortality shown in some studies can be an effect of learning curve or of improvement over time in management of these difficult patients. Further studies are required to clarify this issue.

Minimally invasive repair of a left ventricular pseudoaneurysm after surgical patch reconstruction of an infarct-related free posterior wall rupture: CT-guided intervention

Ventricular free wall rupture remains the most serious complication after acute myocardial infarction. In early-recognized, subacute cases a surgical intervention using patches can be lifesaving. However, in the rare case of postoperative patch leakage, a relapse of a pseudoaneurysm may occur. This is the first case in the literature--to the best of our knowledge--describing a minimally invasive strategy using CT fluoroscopic guidance to perform an injection of thrombin into the perfused pseudoaneurysm to seal a leakage. This therapeutical regimen was chosen--in accordance with cardiac surgeons, cardiologists, and interventional radiologists--due to the high risk of adverse event after repeated surgery in this particular patient. The follow-up images showed complete occlusion of the pseudoaneurysm after the thrombin injection. This approach could be discussed in a multidisciplinary setting in similar cases, especially due to the described negligible recurrence rate after successful initial thrombosis after treating femoral pseudoaneurysms, pseudoaneurysms of the pancreatic artery, or even endoleaks after stenting of aneurysms of the aorta.

Contemporary performance of surgical ventricular restoration procedures: data from the Society of Thoracic Surgeons' National Cardiac Database

BACKGROUND

Surgical ventricular restoration (SVR) is an operation that demonstrates promise to improve outcomes for patients with left ventricular dysfunction. Current use and operative outcomes of SVR have come from centers of expertise, and operative risks of SVR in community practice are unknown. We sought to characterize the performance of SVR nationally and describe the acute risks of mortality and major morbidity plus predictors of adverse outcomes.

METHODS

We identified patients undergoing an SVR procedure at US hospitals participating in the Society of Thoracic Surgeons (STS) National Cardiac Database from January 2002 to June 2004. Baseline characteristics, operative characteristics, clinical outcomes, and predictors of adverse procedural outcomes were analyzed.

RESULTS

There were 731 patients who underwent SVR at 141 of STS's 576 hospitals, and 20 centers performed 10 SVR procedures or more. The operative mortality was 9.3%; reoperation in 14.1%, stroke in 3.3%, renal failure in 8.1%, and prolonged ventilation in 21.5%. Combined death or major complications occurred in 33.5%. Major predictors of this combined end point were age, female sex, creatinine > or = 2 mg/dL, insulin-dependent diabetes, myocardial infarction within 1 week, history of congestive heart failure, 3-vessel coronary disease, severe mitral insufficiency, and status of surgery.

CONCLUSION

This study provides a first look at use and outcomes of SVR in a national sample. Although a quarter of STS sites are performing SVR, most have limited experience and perioperative events are somewhat higher than prior selected series. Further studies of SVR are needed to improve patient selection and procedural performance.

Septal anterior ventricular exclusion operation (Pacopexy) for ischemic dilated cardiomyopathy: treat form not disease

Objective: Restoration of left ventricle size and shape is an effective surgical procedure in patients with dilated cardiomyopathy. This report defines early and intermediate results following the reshaping of the left ventricle from spherical to ellipsoid configuration in patients with ischemic cardiomyopathy, employing a technique for LV restoration (LVR) that uses form rather than disease as the endpoint for oblique patch placement. Methods: Between 1998 and 2004, a cohort of 83 patients with dilated ischemic cardiomyopathy underwent an operation to reshape the left ventricle. In 54 patients the Dor procedure was done, and 29 underwent the septal anterior ventricular exclusion (SAVE) procedure to emphasize the elliptical shape, whereby patch placement followed an oblique trajectory between the LV apex and septum below the aortic valve. Ventricular form, rather than the disease scar marked the suture placement site endpoint to create an ellipse. The mean age was 58 ± 27, but SAVE patients had larger end systolic volume index (135 ± 38 vs 95 ± 25*). Overall preoperative NYHA functional class III was in 69% and IV in 31 patients, but more SAVE patients were in class IV (38% vs 28%*). The procedures were elective in 72 and emergent in 11, with similar entry criteria for each procedure. Results: In combination with LVR operation, mitral surgery was performed in 49/83 and tricuspid annuloplasty in 23/83 patients, but these procedures were more common after SAVE (59% vs 44%* and 45% vs 19%*, respectively), because of larger LV volumes in SAVE patients; 2.8 ± 1.3 coronary artery bypass grafts were used. Perioperative use of IABP or LVAD was 15 and 1, respectively in 83 patients. Hospital death was in 1/11 or 9% after emergent operations and 3/72 or 4% in elective procedures, with no difference between groups. After discharge from the hospital, NYHA class improved to class I or II in 57 patients, class III/IV in 14 patients, with 10 late deaths. The 5-year survival rate after the elective operation was 80.3% in SAVE and with elective operation and 77.4% in the Dor procedure. Conclusion: The SAVE or Pacopexy technique is easy to reshape the dilated left ventricle from spherical to ellipsoid form after the LVR, and the resultant improved configuration may contribute to the overall results for patients with ischemic dilated cardiomyopathy.

Surgical alternatives for the palliation of heart failure: a prospectus

BACKGROUND

Congestive heart failure (CHF) is the leading cause of hospital admissions in the United States.

METHODS AND RESULTS

CHF has a variety of palliative options for treatment and 1 curative one: cardiac transplantation. Palliative medical therapies are often limited in effectiveness by progression of the disease or patient intolerance. Because of limited donor availability, alternative surgical strategies are now being relied on for palliation of patients in end-stage CHF.

CONCLUSION

In this manuscript, we review the principles, outcomes, and practices of some of these surgical strategies often used in the palliation of end-stage CHF.

Surgical Ventricular Remodeling for Patients with Clinically Advanced Congestive Heart Failure and Severe Left Ventricular Dysfunction

BACKGROUND

Surgical ventricular remodeling (SVR) is an accepted therapy for post-infarction ventricular remodeling. Current literature on SVR outcomes has focused on heterogeneous populations with regard to left ventricular function and New York Heart Association (NYHA) class. We assessed outcomes after SVR in patients with advanced congestive heart failure (CHF) (NYHA Class III/IV) and a pre-operative ejection fraction (EF) < or =20%.

METHODS

Data were analyzed for 51 consecutive SVR patients from January 2002 to June 2004. Cardiac catheterization, echocardiography and magnetic resonance imaging (MRI) identified 62.7% (32 of 51) of patients with an EF < or =20%, with the majority having an EF < or =15% (65.6%; 21 of 32). Cox regression analysis was performed to determine predictors of mortality in patients with an EF < or =20%. Follow-up was 100% (32 of 32) complete.

RESULTS

Mean age was 61.9 +/- 10.3 (range 40 to 80) years with a male:female ratio of 27:5. Operative mortality was 6.3% (2 of 32). Twenty-two percent (7 of 32) had concomitant mitral valve procedures. Follow-up demonstrated a statistically significant improvement in left ventricular volumes and EF in survivors. Cox regression analysis identified the following to be significant predictors of mortality: pre-operative left ventricular end-systolic volume index >130 ml/m2; pre-operative diabetes; and intra-aortic balloon pump usage. Pre-operatively, all patients (32 of 32) were categorized as NYHA Class III/IV, with 69% (22 of 32) improving to NYHA Class I/II at follow-up (p < 0.01). Survival did not differ statistically between patients with an EF < or =20% and an EF >20% (n = 19).

CONCLUSIONS

Our results indicate that SVR improves left ventricular function and functional status for patients with advanced CHF and a pre-operative EF < or =20%. Therefore, SVR is a viable surgical alternative for patients with severe left ventricular dysfunction.

Absent Long-Term Benefit of Patch Versus Linear Reconstruction in Left Ventricular Aneurysm Surgery

BACKGROUND

Endoventricular patch reconstruction of the left ventricle is considered the gold standard in surgery for left ventricular aneurysms, because of improved preservation of ventricular geometry. However, the superiority over conventional linear closure has not been demonstrated, as assessed by the long-term outcome.

METHODS

Two hundred patients (66%) underwent linear closure (group L) and 105 patients (34%) had endoventricular patch reconstruction (group D) using the Dor technique. Linear closure has been performed since 1974 and from 1985 on the Dor technique has been applied as an alternative procedure. Both patient groups differed regarding age, sex distribution, site of infarction, and indication for surgery. Prior to the operation, 71% of the patients were in New York Heart Association (NYHA) class III or IV and mean ejection fraction was 34% +/- 12%. Follow-up extends up to 25 years, with a cumulative total of 2,605 patient years.

RESULTS

Early mortality was 6.5% in group L vs 5.7% in group D (not significant [NS]). Actuarial survival after 10 years was 56 +/- 3.2%, with no difference between groups. Freedom from reoperation after 10 years was 95.6% in group L vs 95.2% in group D (NS). Preoperative risk factors for late mortality were age, left ventricular enddiastolic volume index and concomitant mitral valve surgery. The type of procedure and the date of operation had no influence on mortality. To date, 63% of the survivors are in NYHA class I and II.

CONCLUSIONS

In regard to long-term survival, rate of reoperation, and postoperative NYHA functional class, no benefit could be demonstrated when linear closure was compared with ventricular patch reconstruction for LV aneurysm repair. Hence, the technique of ventricular reconstruction may not be as important as previously thought, and at least for small aneurysms the simple and time sparing technique of linear closure may still be considered.

Surgical ventricular restoration and other surgical approaches to heart failure

Historically, few patients with ischemic congestive heart failure (CHF) have been considered for cardiac surgical intervention unless there was an obvious need for coronary revascularization or valve repair. New surgical procedures and non-mechanical assist devices are being used and tested in patients with end-stage CHF. We report on The Ohio State University Medical Center's early involvement in the international and multi-institutional Surgical Treatment for Ischemic Heart Failure (STICH) trial, which is evaluating the value of coronary artery bypass in patients with ischemic CHF as compared to medical therapies alone, and whether surgical ventricular restoration (SVR) offers additional benefit to patients with dilated hearts undergoing revascularization. Beyond standard coronary revascularization and SVR, new surgically deployed devices that attempt to augment ventricular performance by direct restraint of left ventricular dilatation or by reducing ventricular wall stress through altering ventricular shape are reviewed. The growing clinical and experimental experience with cellular cardiomyoplasty (in particular, autologous skeletal myoblast and adult-derived stem transplantation) also is reviewed. This review is intended to express the institutional insights of the authors, who have been involved in clinical trials and basic science research in each of these areas.

Surgical ventricular restoration in end-stage ischemic cardiomyopathy patients

BACKGROUND

Surgical ventricular restoration (SVR) has generally been contraindicated in patients with an ejection fraction (EF) <20%, with pulmonary arterial (PA) pressure >60 mm Hg, and being treated with inotropic agents.

PATIENTS AND METHODS

The patients in this study were 6 men and 5 women 50 to 78 years of age (mean, 62.4 years). Three patients were in New York Heart Association (NYHA) class III with an EF <30%. Eight patients were in NYHA class IV with EF <20%, PA pressure >70 mm Hg, and left ventricular asynergy. Three patients had had recent myocardial infarction (MI) with shock and multiple organ failure. Three patients had mitral regurgitation, 1 patient had ventricular septal defect (VSD), 4 patients had diabetes mellitus, and 5 had morbid obesity. All patients underwent intraoperative transesophageal echocardiography and were being treated with milrinone or nesiritide. Seven patients had intraaortic balloon pumps. All patients underwent coronary artery bypass (CAB), receiving 1 to 5 (average, 3.54) grafts per patient. The SVR (Dor) procedure was performed with a Chase Mannequin device. Preoperative end-diastolic volume was 240 to 330 mL, and postoperative volume decreased to 110 to 130 mL. Two patients underwent mitral valve repair, and 1 underwent VSD closure. One patient underwent microwave ablation for atrial fibrillation.

RESULTS

Ten (91%) of 11 patients were discharged home in 10 to 14 days. There was 1 death: A 78-year-old man with acute MI died 43 days later of septic shock due to hemodialysis.

CONCLUSION

End-stage ischemic cardiomyopathy patients with EF <20% can safely undergo surgery after meticulous preoperative preparation to decrease PA pressure, pulmonary capillary wedge pressure, and peripheral vascular resistance and to increase CO by SVR, CAB, and correction of associated lesions. Mortality was 9% with improved hemodynamics and relief of congestive heart failure in all survivors for 3 to 12 months.

Ventricular reconstruction or aneurysm repair using a modified linear repair technique with septal patch when indicated

A presentation of our approach for ventricular reconstruction or aneurysm resection which includes a modified linear closure plus septal patch technique when indicated. Our philosophy regarding reconstruction combined with coronary artery bypass grafting (CABG) versus revascularization alone is reviewed. When reconstruction is indicated, the surgical approach is planned on the basis of information gained from preoperative angiography and study of ventricular anatomy as defined by magnetic resonance imaging (MRI). At operation, the precise limits of resection are determined in the open beating heart by inspection and palpation. Reasons for choosing this approach are given. Techniques for optimizing size and shape of the residual cavity are described. Technique of septal patch exclusion will be outlined. Additional maneuvers for prevention of ventricular arrhythmias will be discussed. Operative mortality and long term results obtained using this approach are reviewed.

Surgery for left ventricular aneurysm: Early and late survival after simple linear repair and endoventricular patch plasty

OBJECTIVE

Simple linear resection and endoventricular patch plasty are alternative techniques to repair postinfarction left ventricular aneurysm. The aim of the study was to compare these 2 methods with regard to early mortality and long-term survival.

METHODS

We retrospectively reviewed 159 patients undergoing operations between 1989 and 2003. The epidemiologic design was of an exposed (simple linear repair, n = 74) versus nonexposed (endoventricular patch plasty, n = 85) cohort with 2 endpoints: early mortality and long-term survival. The crude effect of aneurysm repair technique versus endpoint was estimated by odds ratio, rate ratio, or relative risk and their 95% confidence intervals. Stratification analysis by using the Mantel-Haenszel method was done to quantify confounders and pinpoint effect modifiers. Adjustment for multiconfounders was performed by using logistic regression and Cox regression analysis. Survival curves were analyzed with the Breslow test and the log-rank test.

RESULTS

Early mortality was 8.2% for all patients, 13.5% after linear repair and 3.5% after endoventricular patch plasty. When adjusted for multiconfounders, the risk of early mortality was significantly higher after simple linear repair than after endoventricular patch plasty (odds ratio, 4.4; 95% confidence interval, 1.1-17.8). Mean follow-up was 5.8 +/- 3.8 years (range, 0-14.0 years). Overall 5-year cumulative survival was 78%, 70.1% after linear repair and 91.4% after endoventricular patch plasty. The risk of total mortality was significantly higher after linear repair than after endoventricular patch plasty when controlled for multiconfounders (relative risk, 4.5; 95% confidence interval, 2.0-9.7). Linear repair dominated early in the series and patch plasty dominated later, giving a possible learning-curve bias in favor of patch plasty that could not be adjusted for in the regression analysis.

CONCLUSIONS

Postinfarction left ventricular aneurysm can be repaired with satisfactory early and late results. Surgical risk was lower and long-term survival was higher after endoventricular patch plasty than simple linear repair. Differences in outcome should be interpreted with care because of the retrospective study design and the chronology of the 2 repair methods.

Surgical Ventricular Restoration: Technique and Outcomes

Surgical ventricular restoration is a surgical procedure developed in an attempt to reverse the negative remodeling that occurs following myocardial infarction. The goal of the procedure is to: 1) reduce the size and restore the normal elliptical shape of the heart; 2) perform a complete myocardial revascularization; and 3) repair any mitral insufficiency. This article will review the surgical procedure and describe outcomes achieved with surgical ventricular restoration.

Left ventricular reconstruction: Early and late results

OBJECTIVES

In patients with coronary disease and poor left ventricular function, ventricular reconstruction with revascularization is a surgical option. Details of patient selection and optimal surgical technique are still debated. This study reports results achieved with ventricular reconstruction in 285 patients who had akinesia or dyskinesia associated with relative wall thinning.

METHODS

Data were prospectively collected. Reconstruction on the beating heart was accomplished by a modified linear closure plus septoplasty, when indicated, (dyskinetic septum). Preoperatively, 237 (83%) were in symptom class III or IV with congestive heart failure (n =174; 61%), angina (n = 157; 55%), or ventricular tachycardia (n = 107; 38%). Average ejection fraction was 24% +/- 11%, and 144 (51%) had preoperative grade 2+ mitral regurgitation. Operative procedures included coronary artery bypass grafting in 262 (92%), septoplasty in 64 (22%), ablation of ventricular tachycardia in 118 (41%), and a mitral valve procedure in 6 (2%).

RESULTS

Operating room mortality was 2.8%. Perioperative support included intra-aortic balloon pumping in 49 (17%) and inotropic drugs in 154 (54%). During a mean follow-up of 63 +/- 48 months, 8 patients required transplantation (interval of 49 +/- 41 months), 2 needed mitral valve replacement, and 9 required use of an implantable cardioverter-defibrillator for ventricular tachycardia. At 1, 5, and 10 years actuarial survivals were 92%, 82%, and 62%. Freedom from sudden death was 99%, 97%, and 94%. Among survivors, symptom class improved in 140 of 208 patients (67%), mean improvement 1.3 +/- 1.1 functional class per patient. Average increase in ejection fraction postoperatively was 10% +/- 9%.

CONCLUSIONS

Using wall thinning as a criterion for patient selection, left ventricular reconstruction can be performed with low operative mortality, provides good control of symptoms, excellent long-term survival, and freedom from sudden death. This approach should be considered in all patients with coronary disease, poor left ventricular function, and relative wall thinning.

Surgical remodeling of left ventricle

In the future, we can certainly expect better assessment of myocardial wall, LV morphology, and performance, with careful approach and analysis of CMR allowing us to check exactly the morphology and volume performances of the LV, and chiefly the wall itself (Fig. 6). Perhaps it will be possible to have a hope of recovery for dilated but nonscarred myocardium, through a combination of currently existing surgical treatment (LVR + myocardial revascularization + mitral repair) and new techniques such as LVAD in appraisal, to help the nondiseased and tired myocardium, and suppress the immune or the autogenous hormonal reaction and let antagonist drugs be efficient. Analysis of some results published by the Berlin Heart Center in Berlin, Germany and others from Magdi Yacoub, MD (personal communication, 2002) showed improvement in LV wall thickness and contraction after months of left ventricular assistance, allowing weaning the idiopathic cardiomyopathy patient from assistance (bridge to recovery). Similar management may be possible in ischemic cardiomyopathy, where the LV wall is not uniformly diseased--one part is a scar and one part is dilated with living perfused myocardium. The synthesis of surgery (LVR) for the scarred area and medical treatment and mechanical support for the dilated portion can become the future method to treat severe end-stage ischemic congestive heart failure. The potential of adding cellular therapy to stimulate growth in the viable distended myocardium is perhaps a further promising complement of this treatment.

The beating heart approach is not necessary for the dor procedure

BACKGROUND

Ventricular reconstruction using the Dor technique has been demonstrated to improve outcome in patients with dilated left ventricles. It has been suggested that a beating heart approach improves ventricular function by allowing the surgeon to palpate that part of the ventricle to exclude.

METHODS

We performed a retrospective analysis of patients who underwent an endoventricular circular patch plasty (Dor procedure) between 1998 and 2001. All patients who received ventricular restoration, with or without revascularization or valve repair, were included in the analysis. Discrete left ventricular aneurysms were excluded. Patients were divided into two groups: group 1 (n = 15) underwent ventricular reconstruction with the beating heart technique, whereas group 2 (n = 38) underwent restoration with the aorta cross-clamped. Clinical and hemodynamic data were collected from medical records and computerized databases and compared between the two groups.

RESULTS

Fifty-three patients underwent endoventricular circular patch plasty. All patients had enlarged ventricles (echocardiogram demonstrating unidimensional end-diastolic diameter >/= 6.0 cm) and echocardiographic evidence of severe left ventricular dysfunction (mean ejection fraction: group 1 = 21.4%; group 2 = 23.4%). No operative mortalities occurred in either group and all patients were discharged home alive (mean postoperative hospital stay 8.3 days [6 to 22 days]). All patients had improvement in left ventricular function with mean postoperative left ventricular ejection fraction of 36.9% (25% to 52%) in group 1 versus 38.1% (31% to 50%) in group 2, p = 0.081. Ventricular arrhythmias occurred in 5 of 15 group 1 patients and in 9 of 38 group 2 patients. Two patients in the entire cohort (1 patient in group 1, and 1 patient in group 2) had at least one readmission within 12 months with evidence of heart failure. The group 1 patient went on to successful transplant 11 months later, whereas the group 2 patient died 10 months later.

CONCLUSIONS

These results demonstrate that the Dor technique of ventricular restoration significantly improves left ventricular function and the beating heart approach provides no additional advantage over continuous aortic cross clamping.

Repair of left ventricular aneurysm: surgical risk and long-term survival

BACKGROUND

The aim of the study was to identify predictors for survival after repair of postinfarction left ventricular aneurysm.

METHODS

We retrospectively reviewed the records of 149 patients who had an operation for postinfarction left ventricular aneurysm between 1989 and 2001. The following variables were recorded: preoperative clinical, angiographic, and echocardiographic findings and operative procedures. Outcomes were early mortality (<30 days) and long-term survival. Risk factors were pinpointed using t test or Mann-Whitney test, contingency tables, and survival curves. Independent risk factors were identified by logistic regression and Cox regression methods. Mean follow-up was 5.8 years (range, 0 to 13.8 years).

RESULTS

The early mortality (<30 days) rate was 8.7% altogether, and the 5-year cumulative survival rate was 77%. Advanced age, history of ventricular arrhythmia, three-vessel disease, and linear repair technique were independent risk factors for early and total mortality. Poor left ventricular function predicted reduced long-term survival but did not increase surgical risk. Survival was not affected by gender, diabetes, type and severity of symptoms, anterior or posterior aneurysm, revascularization of the left anterior descending artery, or number of distal anastomoses.

CONCLUSIONS

Postinfarction left ventricular aneurysm can be repaired with acceptable surgical risk and long-term survival. Survival is reduced in cases with advanced age, history of ventricular arrhythmia, three-vessel disease, poor left ventricular function, and linear repair of the aneurysm.

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.

Ventricular reconstruction for ischemic cardiomyopathy

Left ventricular surgical reconstruction has been advocated for patients with coronary artery disease, prior myocardial infarction, and poor left ventricular function. The objective of the approach is to resect or exclude all akinetic or dyskinetic nonfunctioning portions of the ventricular cavity and to restore the left ventricle size and shape toward normal as much as possible. We review the pathophysiology of ischemic cardiomyopathy and suggest guidelines for preoperative assessment and patient selection for ventricular reconstruction. Because of the prevalence and prognostic significance of ventricular arrhythmias in this patient population we include in our operative approach a visually directed ablation procedure in those with significant septal scarring. We describe our operative technique and review results achieved with this approach. The procedure results in a significant decrease in ventricular volume, increase in ejection fraction and improvement in apical geometry. We conclude that in selected patients with ischemic cardiomyopathy, left ventricular reconstruction can be accomplished with low operative mortality and results in significant improvement in left ventricular function. During follow up symptom class is decreased in most patients and overall survival at 5 years is 84% and freedom from sudden death is 96%. Ventricular reconstruction should be considered in all patients with coronary artery disease and akinetic or dyskinetic scar.