Blood perfusion status is important in the prognosis of ventricular aneurysm complicated by ventricular septal rupture

AIMS

Due to its low incidence, poor prognosis, and high mortality in the acute phase, the long-term prognosis of the left ventricular aneurysm (LVA) complicated by ventricular septal rupture (VSR) has received little attention. This study focus on the long-term prognosis of patients with LVA complicated by relatively stable VSR.

METHODS AND RESULTS

Over a decade of retrospection, 68 patients with both LVA and VSR were compared with 136 patients with LVA alone after propensity score matching. Patients with both LVA and VSR were further divided into two groups depending on whether pre-operative intra-aortic balloon pump (IABP) was used (23 pre-operative IABP vs. 45 non-pre-operative IABP). The primary endpoint was defined as major adverse cardiovascular and cerebrovascular events, a composite endpoint including mortality, myocardial infarction, revascularization, stroke, and heart failure. Patients with both LVA and VSR were generally in a worse condition upon admission compared with those with LVA alone [percentage of patients in New York Heart Association IV: 42.6% (29/68) vs. 11.0% (15/136), P < 0.001]. Both pre-operative and post-operative IABP use rates were significantly higher in patients with both LVA and VSR than in patients with LVA alone [pre-operative IABP use rates: 33.8% (23/68) vs. 0.74% (1/136), P < 0.001 and post-operative IABP use rates: 33.8% (23/68) vs. 10.3% (14/136), P < 0.001]. No significant difference was observed in the primary endpoint between patients with both LVA and VSR and those with LVA alone (log-rank test, P = 0.63, median follow-up time 63 months). We further investigated the effect of pre-operative IABP on the long-term prognosis of patients with both LVA and VSR. Patients who applied pre-operative IABP had a worse long-term prognosis than those who did not (log-rank test, P = 0.0011).

CONCLUSIONS

The long-term prognosis of LVA combined with VSR was not inferior than LVA alone after surgery, but poor blood perfusion status was associated with a worse prognosis.

Ventricular apical wall rupture and ventricular aneurysm formation concurrent with ventricular septal dissection and rupture due to ST-segment elevation myocardial infarction: a case report

The most common mechanical complications of acute myocardial infarction include free-wall rupture, ventricular septal rupture (VSR), papillary muscle rupture and pseudoaneurysm. It is rare for a patient to experience more than one mechanical complication simultaneously. Here, we present a case of ST-segment elevation myocardial infarction (STEMI) complicated with three mechanical complications, including ventricular apical wall rupture, ventricular aneurysm formation and ventricular septal dissection (VSD) with VSR. Cardiac auscultation revealed rhythmic S1 and S2 with a grade 3 holosystolic murmur at the left sternal border. Electrocardiogram indicated anterior ventricular STEMI. Serological tests showed a significant elevated troponin I. Bedside echocardiography revealed ventricular apical wall rupture, apical left ventricle aneurysm and VSD with VSR near the apex. This case demonstrates that several rare mechanical complications can occur simultaneously secondary to STEMI and highlights the importance of bedside echocardiography in the early diagnosis of mechanical complications.

Ignored Role of Paroxysmal Atrial Fibrillation in the Pathophysiology of Cryptogenic Stroke in Patients with Patent Foramen Ovale and Atrial Septal Aneurysm

The association between cryptogenic stroke (CS) and patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) has been a debate for decades in terms of pathophysiologic processes and clinical courses. This issue has become more interesting and complex, because of the concerns associating the CS with so-called normal variant pathologies of interatrial septum, namely ASA and PFO. While there is an anatomical pathology in the interatrial septum, namely PFO and ASA, the embolic source of stroke is not clearly defined. Moreover, in patients with PFO and CS, the risk of recurrent stroke has also been associated with other PFOunrelated factors, such as hyperlipidemia, body mass index, diabetes mellitus, and hypertension, leading to the difficulty in understanding the pathophysiologic mechanism of CS in patients with PFO and/or ASA. Theoretically, the embolic source of cryptogenic stroke in which PFO and/or ASA has been involved can be categorized into three different anatomical locations, namely PFO tissue and/or ASA tissue itself, right or left atrial chambers, and venous vascular territory distal to the right atrium, i.e., inferior vena cava and lower extremity venous system. However, the possible role of paroxysmal atrial fibrillation associated with PFO and/or ASA as a source of cryptogenic stroke has never been mentioned clearly in the literature. This review aims to explain the association of cryptogenic stroke with PFO and/or ASA in a comprehensive manner, including anatomical, clinical, and mechanistic aspects. The potential role of paroxysmal atrial fibrillation and its contribution to clinical course have been also discussed in a hypothetical manner to elucidate the pathophysiology of CS and support further treatment modalities.

Prevalence and factors associated with spontaneous closure of congenital ventricular septal defects

BACKGROUND

Most of congenital ventricular septal defects evolve towards spontaneous closure of different mechanisms depending on their location.

AIM

To determine the prevalence and factors associated with spontaneous closure of congenital ventricular septal defects.

METHODS

We conducted a retrospective study of 1000 patients diagnosed with congenital ventricular septal defects in our department from January 2000 to December 2017.

RESULTS

After an average follow-up of 52.65 months (± 76.93 months), 183 (18.88%) of ventricular septal defects closed spontaneously. The average time for spontaneous closure was 45.78 months (76.34 months). 30.77% of trabecular ventricular septal defects (p<0.05) and 16.93% of perimembranous defects closed spontaneously (p=0.17). 28.5% of perimembranous defects associated with aneurysm formation versus 17.4% of those without associated aneurysm evolved to spontaneous closure (p<0.05). 65.6% of spontaneous closure occured during the first 3 years of life. In multivariate analysis, trabecular site [OR=2.85; CI (2.05-3.97)] and aneurysms of membranous septum [OR=1.9; CI (1.41-2.8)] were independent factors associated with spontaneous closure of defects.

CONCLUSION

The highest VSD closure rate was observed during the first three years of life. Trabecular site and aneurysms tissue of membranous septum were found as independent factors associated with spontaneous closure.

Impact of surgical ventricular restoration on early and long-term outcomes of patients with left ventricular aneurysm: A single-center experience

Left ventricular aneurysm (LVA) is a common complication of myocardial infarction. However, the optimal treatment for LVA remains controversial.In this retrospective study, we analyzed the early and long-term clinical consequences of surgical ventricular restoration on 102 patients who had undergone repair between January, 2005 and January, 2015. The LVA repair approaches comprised of patch plasty (n = 28), linear repair (n = 40), and plication repair (n = 34).Patient demographics were 60.8% male, and the mean age was 60.5 ± 7.2 years. The in-hospital mortality rate was 7.8% (8/102), including 6 patients who died from low cardiac output and 2 from multiorgan failure. During the early postoperative period, left ventricular sizes significantly decreased in the patch plasty and linear repair groups compared with the plication group. In addition, all 3 repair techniques greatly ameliorated left ventricular ejection fraction (P < .05), and there was no significant difference in survival rate between groups (P = .25).Surgical ventricular restoration (linear repair, plication repair, and patch plasty) obtained equivalently appreciable outcomes for cardiac function improvement, perioperative mortality, and survival. Selection of a surgical technique for LVA patients should be optimized to individual patient conditions including the morphological characteristics of the aneurysm and ischemic scar.

A case report of apical aneurysms and myocardial perfusion deficit with myocardial necrosis due to hypertrophic cardiomyopathy

RATIONALE

Hypertrophic cardiomyopathy (HCM) is a disease that is characterized by inappropriate left ventricular and/or right ventricular hypertrophy and hypercontractility that is often asymmetrical and associated with microscopic evidence of myocardial fiber disarray. The aim of this study was to present a previously under-recognized subset of HCM patients with left ventricular (LV) apical aneurysms.

PATIENTS CONCERNS

A 33-year-old man who presented with chest discomfort for 10 days. He had an emerging apical aneurysm in the LV without midventricular obstruction. He had been diagnosed with apical HCM via abnormal electrocardiograms (ECG) and single-photon emission computed tomography (SPECT) for 10 years. This time, a new significant change in ECG and SPECT was identified. Late gadolinium enhancement (LGE) was observed by cardiac magnetic resonance imaging (MRI), and SPECT showed myocardial fibrosis or necrosis involving the apical aneurysm and proximal portion of the heart, which was confirmed by left ventriculography.

DIAGNOSES

We present a relatively rare case of HCM patients with apical aneurysms, accompaning by myocardial necrosis markers increased due to ventricular muscle stress increases, rather than obstructive coronary artery disease.

INTERVENTIONS

The patient was prescribed aspirin, metoprolol tartrate, perindopril, and atorvastatin and was strongly advised to quit cigarettes and reduce weight.

OUTCOMES

Follow-up at half a year turned out well.

LESSONS

LGE with a notable progression by ECG and SPECT along with an increase in myocardial necrosis markers in HCM patients with apical aneurysms, as was noted in the present case, is a relatively rare occurrence. Our present case may provide unique insights into the adverse remodelling process and the formation of apical aneurysms in HCM patients.

Efficacy of cardiac magnetic resonance imaging in a sub-aortic aneurysm case

Sub-aortic (SA) aneurysms are a rare entity of variable aetiology. We report the first case of a SA aneurysm assessed using cardiac magnetic resonance imaging (MRI). A 33-year-old female with human immunodeficiency virus and on highly active antiretroviral treatment presented with syncope and dyspnoea. Clinical examination suggested moderate to severe aortic regurgitation (AR) confirmed by transthoracic and transoesophageal echocardiograms. However, echocardiography was suboptimal in defining the precise mechanism and severity of AR. A cardiac MRI was done to elucidate the aetiology, severity and mechanism of regurgitation. It confirmed the presence of a SA aneurysm below the left coronary cusp and its retraction, resulting in an eccentric AR jet. An assessment of moderate AR, based on regurgitant volume, was made. Furthermore, the anatomical relationships of the aneurysm were clearly defined. Cardiac MRI allowed comprehensive assessment of this SA aneurysm.

A Bleeding Heart: Coronary-Cameral Fistula After Septal Myomectomy

Coronary-cameral fistulas are relatively rare communications arising within the coronary vasculature entering into one of the four cardiac chambers. This case highlights a striking angiographic example of coronary-cameral fistula occurring after septal myomectomy, a complication occurring somewhat frequently with typical spontaneous resolution.

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.

Endoaneurysmorrhaphy for a Giant Inferobasal Left Ventricular Aneurysm Restoring Mitral Function

Over the years, the surgery of ventricular postinfarction aneurysm has evolved from linear resection to endoaneurysmorrhaphy using a patch. Technically, several aims that include the restoration of ventricular shape and function, exclusion of dead space, minimization of the risk of thrombus formation and restoration of valve function are pursued. Herein is reported the case of a 58-year-old male with a giant inferobasal aneurysm involving the mitral valve apparatus who underwent successful endoaneurysmorrhaphy. Correct sizing of the patch proved to be the 'road to success' in this patient. The present case is the second reported instance of a giant ventricular aneurysm involving the mitral valve, with favorable outcome.

Clinical characteristics and outcomes of left ventricular pseudoaneurysm: A retrospective study in a single-center of China

Left ventricular (LV) pseudoaneurysm is a fatal and rare condition with a high risk of rupture. The symptoms are nonspecific and diagnosis is often delayed. The purpose of this study is to analysis a series of cases in our institution.Between March 2009 and April 2016, 10 patients (5 males and 5 females) with LV pseudoaneurysm were retrospectively enrolled. Clinical information, diagnostic imaging modalities, treatment, and outcomes were evaluated.The mean age was 58.2 ± 11.0 years (28-71 years). The common symptoms were chest pain (3 cases), dyspnea (3 cases), and syncope (2 cases). All patients had nonspecific abnormalities on the electrocardiogram, and 7 patients had chest X-ray abnormalities. Three etiologies including myocardial infarction (6 cases), mitral valve replacement (3 cases), and suspected endocarditis (1 case) were identified. LV pseudoanerysm was diagnosed in 8 patients by transthoracic echocardiography, and the other 2 patients were diagnosed by computed tomography angiogram. Posterior (4 cases) and lateral (4 cases) of the left ventricle were the most common positions of the rupture orifice. Eight patients accepted surgery repair and 2 patients were treated conservatively. In 2 patients, residual apical aneurysm was found, 1 patient was detected with a residual LV pseudoaneurysm, and 1 patient had myocardial infarction at 61 months' follow-up.Myocardial infarction was the most common etiology of patients with LV pseudoaneurysm. The most frequently ruptured orifices were lateral and posterior walls of the left ventricle. Surgery is recommended as the first option, and conservative therapy can be considered for appropriate patients.

The Role of Multimodality Imaging in a Case of Traumatic Cardiac Pseudoaneurysm

After a 40-foot fall from a balcony, a healthy 21-year-old sustained multiple injuries, including left ventricular pseudoaneurysm. This case demonstrates the critical necessity of the combination of a high index of suspicion and multimodality imaging for diagnosis and prompt intervention.

Acute coronary syndrome and platypnoea-orthodeoxia with thoracic and interauricular septal aneurysms

OBJECTIVE

Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea induced by the upright position and relieved by supine position and an arterial deoxygenation increased by the upright position which improves during recumbency. Several anatomical factors that can alter the atrial anatomy and facilitate shunting through an interatrial defect have been related to this syndrome. In many cases, this syndrome has been associated with patent foramen ovale (PFO) and right-to-left shunt. Rarely platypnea-orthodeoxia syndrome has been described associated with an aortic and with an interauricular septal aneurysm too.

CASE PRESENTATION

We present a case of platypnea-orthodeoxia syndrome in a 85-year-old woman with patent foramen ovale, interauricular septal aneurysm and ascending aortic aneurysms who was admitted for an acute coronary syndrome which could be of embolic origin and was responsible for ventricular fibrillation during the transfer to the hospital. PFO closure was performed by percutaneous device and right coronary artery obstruction was treated by transluminal angioplasty and stenting.

Magnetic resonance imaging of AMS (Aneurysm of the Membranous Septum), review of the literature and case report

Aneurysm of the Membranous Septum (AMS) is a rare cardiac disease, mostly associated with other cardiac anomalies, very rare in the absence of other congenital heart defects. A prompt diagnosis is important, due to severe potential complications, but remain challenging. Most of the cases were earlier diagnosed using ventriculography, but, with the availability of echocardiography and cardiovascular magnetic resonance (CMR), this disease can be accurately assessed non-invasively. We report a case of a 62 years old female patient, without other cardiac congenital disease, who was incidentally diagnosed, by means of CMR with a true and isolated AMS. Our report underlines CMR usefulness in AMS diagnosis, thanks to accurate evaluation (both morphologic and functional) provided by this diagnostic tool, which is able to demonstrate clearly the presence of AMS (aneurysm of the membranous septum) and depict its features.

Epicardial catheter-based ventricular reconstruction: a novel therapy for ischaemic heart failure with anteroapical aneurysm

OBJECTIVES

Surgical ventricular reconstruction has been used to treat ischaemic cardiomyopathy with large akinetic or dyskinetic areas. However, application of this approach requires a sternotomy, cardiopulmonary bypass and a left ventriculotomy. This study assessed the feasibility and efficacy of minimally invasive, off-pump, epicardial catheter-based ventricular reconstruction (ECVR) in an anteroapical aneurysm ovine model.

METHODS

Left ventricular (LV) anteroapical myocardial infarction was induced percutaneously by coil embolization of the left anterior descending coronary artery. Eight weeks after infarction, via mini left thoracotomy and without cardiopulmonary bypass, ECVR was performed in six sheep. The scar was excluded by placing anchor pairs on the LV epicardial anterior wall and the right ventricular side of the interventricular septum under fluoroscopic guidance. LV performance was evaluated before, immediately after device implantation and after 6 weeks by echocardiography. Terminal histopathology was performed.

RESULTS

ECVR was completed expeditiously in all animals without complications. Parameters obtained 6 weeks after device implantation were compared with baseline (pre-device). End-systolic volume was decreased by 38% (25.6 ± 6.1 ml vs baseline 41.2 ± 7.2 ml, P = 0.02) with preservation of stroke volume. Ejection fraction was significantly increased by 13% (48.5 ± 7% vs baseline 35.8 ± 7%, P = 0.02). The circumferential strain in the anterior septum (-7.67 ± 5.12% vs baseline -0.96 ± 2.22%, P = 0.03) and anterior wall (-9.01 ± 3.51% vs baseline -4.15 ± 1.36%, P = 0.01) were significantly improved. The longitudinal strain in apex was reversed (-3.08 ± 1.53% vs baseline 3.09 ± 3.39%, P = 0.01). Histopathology showed full endocardial healing over the anchors with appreciable reduction of the chronic infarct in the LV.

CONCLUSIONS

ECVR without cardiopulmonary bypass is a less invasive alternative to current standard therapies, reverses LV remodelling and improves cardiac performance in an ovine model of anteroapical aneurysm.

LEFT VENTRICULAR INFLOW OBSTRUCTION BY GIANT ATRIAL SEPTAL ANEURYSM IN A NEONATE WITH HYPOPLASTIC RIGHT HEART SYNDROME: CASE REPORT

Atrial septal aneurysm remains a rare congenital cardiac malformation. In the neonatal age group it can occur as an isolated cardiac malformation or in association with complex hypoplastic cardiac malformations of the right and left heart. In the adult population most aneurysms have been described in association with stroke. Baby H.N delivered on 10/05/2008 by C/S, was cyanosed at birth with systemic desaturation. Chest X-ray showed oligaemic lung fields while two dimensional echocardiograms showed tricuspid atresia with hypoplastic right ventricle, large secundum atrial septal defect, and highly mobile gigantic aneurysms of the atrial septum obstructing the inflow of the mitral valve and entering the left ventricle in diastole. Surgical intervention was not possible and child died on second day.

[Results of plasty of postinfarction left ventricular aneurysm performed on the working heart]

The results of plasty (124 patients) of postinfarction left ventricular aneurysm performed on the working heart are presented in this article. It is shown, that the upgrade of existing surgical techniques, which are directed to the creation of the optimal left ventricle shape, could improve the clinical results after plasty of postinfarction left ventricular aneurysm. It's important to arrange the conditions, which allow avoiding a negative influence on contractility function of the myocardium. The desired conditions could be obtained, if the plasty is performed on the working or fibrillating heart provided that the patient has a consistent aortic valve.

[Features of cardiomyocytes structural changes in patients with postinfarction aneurism and reduced myocardial contractility of the left ventricle of the heart]

Cardiomyocytes (CMC) of 18 patients with both ischemic heart disease, aneurism of the front wall and reduced myocardial contractility of the left ventricle (LV) were hypertrophied and in state of chronic hibernation, which was characterized by weakening of tissue-specific signs. Widening of lack myofibrils' zones and in part gap junction of intercalated disk transfer on the side of cells was found The hypertrophy of CMC had positive correlation, but chronic hibernation - negative one with the volume of LV. The worse prognosis of clinical course was degenerative changes of hibernate CMC with accumulation of autophagosomes that correlated with increasing of LV sphericity index.

Left ventricular assist device implantation combined with surgical ventricular reconstruction

Nine months after sustaining a transmural anteroseptal myocardial infarction, a 45-year-old man presented with ischemic heart disease, severe mitral valve insufficiency, New York Heart Association functional class IV congestive heart failure, and a left ventricular aneurysm. Coronary angiography revealed 3-vessel disease. Echocardiography showed severe left ventricular impairment, pronounced thrombosis in the left ventricular apex, and low myocardial reserve. To reduce the high risk of performing left ventricular and mitral valve reconstruction concurrently with revascularization, we decided to perform ventricular reconstruction and to implant a Berlin Heart INCOR left ventricular assist device as a bridge to heart transplantation. The patient had an uncomplicated recovery, was discharged from the hospital with symptomatic improvement after 20 days, and was placed on the list for heart transplantation. We describe the patient's case, the surgical procedure, and the reasoning behind the chosen course of treatment.

Simultaneous pressure recording in mid-ventricular obstructive hypertrophic cardiomyopathy

A 70-year-old man was diagnosed with mid-ventricular obstructive hypertrophic cardiomyopathy (MVOHCM) with apical aneurysm and paradoxic jet flow. At cardiac catheterization, pressure study showed that there was a markedly high pressure-gradient of 90 mmHg between the apex and the base in systole. Apical pressure was 350 mmHg after premature ventricular contraction. The apical aneurysm was already dilated and spherical in late systole; the absence of active relaxation was considered to be the cause of the paradoxic jet flow. In this report, we suggest the pathogenesis of left ventricular apical aneurysm and paradoxic jet flow in MVOHCM.

Pseudoaneurysm of the left ventricle following apical approach TAVI

Symptomatic severe aortic stenosis carries a two year survival of only 50%. However many patients are unsuitable for conventional aortic valve replacement as they are considered too high risk due to significant co-morbidities. Transcatheter Aortic Valve Implantation (TAVI) offers a viable alternative for this high risk patient group, either by the femoral or apical route. This article reports a case of a pseudoaneurysm of the left ventricle following an apical approach TAVI in an elderly lady with severe aortic stenosis. To our knowledge pseduoaneuryms of the left ventricle have been reported infrequently in the literature and has yet to be established as a recognised complication of TAVI.

"Hidden Danger" a case report on interatrial septal aneurysm

In this case cardiac CT angiography has been the tool for evaluation of atrial septal aneurysm. This cardiac malformation is well identified by echocardiographic techniques and cardiac-MRI sequences. Clinical significance due to left atrial dysfunction and increased thrombo-embolic risk has been described independently and in association to cardiac wall defects as patent foramen ovale.

Mid-ventricular obstructive hypertrophic cardiomyopathy with apical aneurysm and sustained ventricular tachycardia: a case report and literature review

The case is a 54-year-old man with hypertrophic cardiomyopathy, mid-ventricular obstruction, apical aneurysm, and recurrence sustained monomorphic ventricular tachycardia (VT). A coronary angiogram revealed myocardial bridging located in the middle of the left anterior descending coronary artery (LAD), and the left ventriculogram showed an hour-glass appearance of the left ventricular cavity. There was a significant pressure gradient of 60 mmHg across the mid-ventricular obliteration at rest. A successful myectomy of the inappropriate hypertrophy myocardium and excision of the apical aneurysm were performed. Pathologic analysis demonstrated fibrosis in the apical aneurysm and thickened and narrowed vessels in the adjacent area. During the follow-up of eighteen months, the patient remained clinically stable and free from arrhythmic recurrence.

[Hypertrophic cardiomyopathy with left ventricular aneurysm]

We present a case of 68 year-old woman with previously diagnosed hypertrophic cardiomyopathy complaining of progressive dyspnoe after the acute coronary syndrome. The echocardiogram confirmed hypertrophic hypertrophy and revealed an aneurysm in the apical portion of the left ventricle (LV). The Doppler-echocardiography showed two intra-LV gradients: midventricular and subaortic, with systolic anterior motion of anterior mitral leaflet.

The impact of surgical ventricular restoration on ischemic mitral regurgitation

OBJECTIVE

The aim of current study was to evaluate and compare the changes in clinical status and mitral regurgitation (MR) grade and long-term postoperative survival after left ventricle surgical restoration (SVR) operations.

MATERIAL AND METHODS

We retrospectively analyzed the data of 139 patients suffering from ischemic heart disease and left ventricular aneurysms or large akinesia, who underwent SVR and coronary artery bypass grafting without MR surgical correction between 1999 and 2006. The mean long-term postoperative follow-up was 3.6 years (SD, 3.0). Nine patients (6.5%) died during the first 30 postoperative days.

RESULTS

The mean MR grade during the long-term period increased significantly. The univariate logistic regression analysis showed that factors for the long-term mortality were age (P=0.002), decompensation signs before SVR (P=0.03), treatment with diuretics (P=0.01), NYHA functional class IV (P=0.008), and moderate and severe MR (P=0.04); however, multivariate logistic regression analysis demonstrated that only patient's age was an independent predictive factor (P=0.004). MR correction was found to be a significant prognostic factor of borderline significance for perioperative mortality (P=0.05). The analysis of MR grade (mild versus moderate versus severe) impact on long-term survival failed to demonstrate any association (P=0.22).

CONCLUSIONS

Remodeling continued during the long-term period after SVR and CABG: there was an increase in the mean MR degree. Left ventricular remodeling with moderate and severe MR decreased survival rates during long-term period after surgical ventricular restoration; however, mitral regurgitation was not found to be an independent predictor of poor outcome.

[Outcomes of surgical management of elderly and aged patients with complicated forms of coronary artery disease]

The article is dedicated to comparative analysis of surgical management of elderly and aged patients presenting with complicated forms of coronary artery disease (CAD). Suggested herein is an algorithm of concerning the choice of methods aimed at surgical correction of postinfarction aneurysms of the right ventricle of the heart and postinfarction ruptures of the interventricular septum in these patients, depending on the morphological structure of the right-ventricular postinfarction aneurysms and postinfarction ruptures of the interventricular septum, followed by determining the incidence rate of using "complete" and "incomplete" myocardial revascularization in elderly and aged patients with complicated forms of CAD depending on peculiarities of the coronary blood flow. Also considered herein is efficacy of preventing rethrombosis following correction of right-ventricular postinfarction aneurysms and thrombectomy. The article is based on studying a total of forty-two 60-to-78-year-old patients with CAD. The measures taken made it possible to decrease postoperative lethality and postoperative complications rate in the patients concerned.

[Effects of left ventricular reconstruction on magnetic resonance imaging derived left ventricular wall stress and contractive function in patients with postinfarction ventricular aneurysm]

OBJECTIVE

To evaluate the effects of left ventricular reconstruction on left ventricular wall stress and function in patients with postinfarction left ventricular aneurysm.

METHODS

During January 2005 to June 2006, 16 patients [15 male, (56.6 +/- 8.8) years] with postinfarction ventricular aneurysm received left ventricular reconstruction operation on CPB (5 linear repair, 6 endoventricular purse-string suture, 5 endoventricular patch repair) and CABG was also performed in 15 patients. MRI examination was made before and 3 months post operation by Siemens Magnetom Avanto 1.5T MR with routine cine-MRI in combination with late-delayed enhancement sequence. Left ventricular geometric parameters and segmental thickening were obtained with accessory image analysis software. Non-invasive blood pressure was acquired in order to compute ventricular wall stress. The revascularized and unrevascularized segments were defined by comparing the post operation revascularization of the blood-supply coronary artery with preoperative results.

RESULTS

A total of 192 segments including 74 unrevascularized segments were analyzed. Segmental thickening were significantly increased while wall stress were significantly reduced in both unrevascularized and revascularized segments 3 months post operation compared to preoperative values (all P < 0.05). The increase of wall thickening was positively correlated with the reduction of wall stress in these segments.

CONCLUSION

Left ventricular reconstruction plus CABG is associated with reduced left ventricular wall stress and increased myocardial contractive function in patients with postinfarction left ventricular aneurysm.

Surgical treatment of left ventricular aneurysm

When a left ventricular aneurysm leads to pulmonary congestive symptoms, aneurysmectomy may provide relief. This retrospective study included 269 patients who underwent aneurysmectomy between 1993 and 2002, by the classic Cooley operation in 164 and by Dor ventriculoplasty in 105. There were no significant differences in early and late survival between groups, although the frequency of extended anteroseptal infarction was higher in patients undergoing the Dor procedure. Postoperative echocardiographic findings showed significant improvements in left ventricular function in both groups, in terms of end-diastolic and end-systolic dimensions and ejection fraction. Left ventricular aneurysmectomy significantly improved the clinical status and hemodynamic parameters of symptomatic patients. The choice of surgical technique depends on the extent of the scar segment, especially the presence of an anteroseptal scarred area. The Dor procedure is more suitable for restoring normal left ventricular geometry in patients with extensive septal infarction.

Unknown ankylosing spondylitis with only cardiac involvement in patient with surgical indication: Call for patient and family members immunological screening

Aortic regurgitation (AR) and first-degree atrioventricular heart block (FDAVB) are encountered in ankylosing spondylitis (AS). This rheumatological disease also presents in 90% of the cases an immunogenetic marker that is Human Leucocyte Antigen-B27 (HLA-B27). In this report we describe a case of a patient presenting with AR, FDAVB, aneurysm and thinning of the ascending aortic wall, aneurysm of the sinuses of Valsalva and inferior myocardial infarction-like electrocardiographic pattern with unknown cardiac AS and absence of other AS-related systemic manifestations.

Review: Mitral valve aneurysms in infective endocarditis: mechanisms, clinical recognition, and treatment

The mitral valve frequently becomes secondarily infected in aortic valve endocarditis. A number of mechanisms have been invoked to explain this association, including: (i) aortic regurgitation (jet lesions); (ii) vegetation prolapse into the left ventricular outflow tract ('kissing lesions'); and (iii) a contiguous spread of infected tissue. A variety of secondary lesions can develop on the mitral valve, including partial thickness ulcerations, perforations, vegetations, and aneurysms. The clinical recognition and treatment of mitral valve aneurysms in primary aortic valve endocarditis are of particular interest and comprise the main focus of this review. Echocardiographically, mitral valve aneurysms appear as narrow-necked, saccular echolucencies protruding into the left atrium. These structures must be distinguished from mitral valve prolapse, congenital diverticula and blood cysts. Mitral regurgitation can result from aneurysm perforation or from the mass effect produced by lesions critically located along the lines of leaflet closure. Aneurysms harboring clot are a potential source of systemic embolization. Treatment is generally surgical; however, otherwise uncomplicated aneurysms have been safely followed using a more conservative strategy.

An uncommon cause of pulsation on the left side of the thorax. Case report

A 70-year-old man affected by clinical findings of congestive heart failure eight months after aneurysmectomy of a true left ventricular aneurysm, presented with actual pseudoaneurysm of the left ventricle. There was a 5 x 5 cm soft tissue mass on the left side of the chest, synchronously pulsating with heart beating. The repair was performed with the aid of cardiopulmonary bypass. Myocardial tissues were approximated and closed by using two Teflon stripes. BioGlue was applied on the sutures and between the stripes. Although there is a significantly high mortality of the pseudoaneurysm cases their repair can and should be performed in an urgent procedure.

Equilibrium radionuclide angiography for evaluating the effect of percutaneous coronary intervention on ventricular aneurysm formation and systolic synchrony in patients with acute myocardial infarction

Left ventricular aneurysm (LVA) after myocardial infarction often results in serious complications. So far, when the LVA happened is unclear. Furthermore, it is a question whether percutaneous coronary intervention (PCI) can change or reverse the formation of LVA? And the report about the long term follow-up was rare. So this study was to evaluate the time sequence of the formation of LVA through left ventriculography in large scale of consecutive acute myocardial infarction (AMI) patients and evaluate the influence of PCI at different time after AMI on the change of systolic synchrony through phase analysis of equilibrium radionuclide angiography. The change of serum brain natriuretic peptide (BNP) was also measured to investigate its association with LVA. And follow up to 3 years to record the major adverse cardiac events. Total of 326 consecutive patients of anterior AMI with LVA were enrolled into this study. All patients were divided into four groups according to the time 'onset to balloon': group A (<3 h), group B (> or =3 and < or =6 h), group C (>6 and < or =12 h) and group D (>1 week). The paradox volume image as well as the parameters of left ventricular function and systolic synchrony were measured by equilibrium radionuclide angiography at 1 week and 6th month after AMI. Plasma BNP was measured in different time after AMI. The major adverse cardiac events were recorded up to 3 years. At the 6th month after AMI, left ventricular ejection fraction, peak ejection rate and peak filling rate in group A, B and C were significantly increased than those in group D while phase shift and peak phase standard deviation were decreased significantly (P < 0.05, respectively). At 6th month after AMI, the paradox volume index in group A was lowered than that in group B, C, and D (P < 0.05, respectively). In 18th hour, 5th day and 24th week after AMI, the values of BNP in group D were higher than those in group A, B and C (P < 0.05, respectively). There was not significantly different between group B and group C. Within the 3rd year follow-up, the incidences of angina post-AMI and mortality in group A, B, and C were significantly lowered than those in group D (P < 0.05, respectively). The LVA can formate shortly after the AMI. The early, fully and permanently patency of infraction related artery can effectively inhibit the left ventricular remodeling process, prevent LVA formation, improve its function and prognosis.

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.

[Surgical left ventricle reconstruction for treatment of heart failure]

INTRODUCTION

Surgical ventricular reconstruction is an option for treatment of heart failure elicited by left ventricular aneurism. The aim of this study was to report the results of such treatment in our tertiary centre.

MATERIAL AND METHODS

From January 2002 through October 2007 surgical ventricular restoration was performed in 26 patients (23 males) with a median age of 64 years (47-74 years). Twenty-one of the patients were in New York Heart Association (NYHA) class III-IV. The median preoperative left ventricular ejection fraction was 27% (13-38%). We collected both pre- and postoperative data retrospectively.

RESULTS

Eighty-five percent of the patients received additional operative procedures, in most cases coronary artery bypass grafting. Ninety-six percent survived the follow-up period which had a median duration of 392 days (1-1777). At follow-up left ventricular ejection fraction had increased to 35% (18-53%) (p < 0.05) and 20 patients were in NYHA class I-II (p < 0.05).

CONCLUSION

Surgical left ventricular reconstruction is a feasible option for treatment of heart failure in patients with post myocardial infarction aneurisms. In selected patients this treatment carries a low mortality and results in improved left ventricular function and functional capacity.

[Clinical study of idiopathic dilated cardiomyopathy complicated by left ventricular aneurysm]

OBJECTIVE

To examine the hemodynamic and electrophysiological influence of left ventricular aneurysm (LVA) formation in patients with idiopathic dilated cardiomyopathy (IDCM).

METHODS

All hospital records were retrospectively reviewed from IDCM patients admitted to our hospital between 2003 and 2008. Patients with coronary angiography evidenced ischemic cardiomyopathy were excluded. IDCM patients with LVA (I + L) diagnosed by left ventriculography were enrolled. Twelve age-, gender- and left-ventricular-diameter- matched patients with IDCM without LVA served as control group (I - L).

RESULTS

Six out of 998 patients with IDCM were confirmed to have LVA (0.60%). The LV peak-systolic pressure was higher in the I + L group than in I - L group [ (130 +/- 10) mm Hg (1 mm Hg = 0.133 kPa) vs. (117 +/-9) mm Hg, P < 0.05]. The LV end-diastolic volume was significantly larger in the I + L group than in I-L group[ (272 +/- 57) ml vs. (207 +/- 60) ml, P < 0.05]. The LV ejection fraction was slightly lower in the I + L group than in I - L group [ (27 +/- 9)% vs. (35 +/- 6)%, P = 0. 09]. Ventricular arrhythmia occurred more frequently in I + L group than in I - L group.

CONCLUSION

LVA formation in IDCM was a rare phenomenon. IDCM patients with LVA seem to have higher LV peak-systolic pressure, larger end-diastolic volume, worse LV systolic function and more frequent ventricular arrhythmia than those without LVA.

[Results of surgical remodeling after resection of aneurysm and plasty by Dor-II-Jatene method in patients with post-infarction aneurysms of the left ventricle]

Post-infarction remodeling was studied in 41 patients with the post-infarction aneurysm of the left ventricle and initially reduced contractive function of the left ventricle myocardium: ejection fraction from 17 to 35%. The ultrasonic pre- and postoperative investigation allowed assessment of the index of the ultimate diastolic volume, index of the ultimate systolic volume, ejection fraction, long axis of the left ventricle, apical short axis, papillary short axis, mitral short axis. In addition, impaired obliquity of the left ventricle cavity and relative thickness of the left ventricle wall and intervenricular septum at different levels were determined. Surgical remodeling using resection of aneurysm and plasty by Dor-II-Jatene method facilitated normalization of indices of the cavity geometry and reestablishment of the contractive ability of the left ventricle.

Right-to-left shunt, atrial septal aneurysm and thrombophilia in patients with cryptogenic stroke or TIA vs. those with venous thrombo-embolism

Whether intracardiac right-to-left shunt (RLS) is an independent risk factor for cerebrovascular accidents is disputed. In patients with RLS, venous thrombo-embolism (VTE) may predispose to paradoxical embolic events, among which stroke and transient ischemic attack (TIA). Whether genetic or acquired thrombophilia is associated with RLS is unclear. Thus, we compared prevalences of intra- and extracardiac intrapulmonary RLS and of atrial septal aneurysm (ASA) between 29 nondiabetic patients with cryptogenic stroke (n=17) or TIA (n=12) and 19 patients with VTE but without history of stroke/TIA, or autoimmune systemic disease or migraine. Carotid atherosclerosis was excluded in all patients. RLS and ASA were also evaluated in 30 healthy volunteers. We found that intracardiac RLS (31%) and ASA (21%) were detected in stroke/TIA patients and not in our selected VTE patients (both p<0.05); however, those prevalences were comparable to those detected in our controls (20% intracardiac RLS, 7% ASA, respectively, both p=NS). Within patients, thrombophilia was not associated with intracardiac RLS, but tended to be associated with ASA (83% in those with vs. 43% in those without ASA, p=0.08). In conclusions, intracardiac RLS may have a role in selected populations in the frame the multi-factorial pathogenesis of stroke/TIA of embolic origin. ASA appears to be an independent risk factor for stroke/TIA with possible interaction with thrombophilia.

Greyscale intravascular ultrasound and IVUS-radiofrequency tissue characterisation to improve understanding of the mechanisms of coronary stent thrombosis in drug-eluting stents

Stent thrombosis is one of the major concerns after drug-eluting stent implantation. Multiple mechanical causes (i.e., stent under-expansion, edge dissection, geographic miss, residual stenosis, incomplete stent apposition and aneurysm) have been postulated. These features are easily identifiable by intravascular ultrasound. However, it is uncertain which of them are inextricably related to stent thrombosis, primarily due to the low number of such patients studied by IVUS in case control studies. Complementary to greyscale IVUS, tissue characterisation by IVUS radiofrequency data (RFD) analysis has the potential to add valuable information on the pathogenesis of stent thrombosis by providing information on plaque composition, specifically on the amount of necrotic core and its location (superficial or deep). However, the clinical utility of IVUS-RFD analysis in this context has yet to be demonstrated.