Asian Cardiovasc Thorac Ann 2007;15:310-312
© 2007 Asia Publishing EXchange Ltd
Left Ventricular Aneurysm in Patients with Previous Cardiac Surgery
Ahmed A Alsaddique, MD,
Anthony P Furnary, MD1
King Fahad Cardiac Center, King Khalid University Hospital, Riyadh, Saudi Arabia
1 St. Vincent Hospital and Medical Center, Portland, Oregon, USA
For reprint information contact: Ahmed A Alsaddique, MD Tel: 966 1 467 1846 Fax: 966 1 467 9493 Email: alsadd{at}hotmail.com, King Fahad Cardiac Center, College of Medicine & King Khalid University Hospital, PO Box 7805, Riyadh 11472, Saudi Arabia.
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ABSTRACT
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Left ventricular aneurysm in patients who have undergone previous cardiac surgery is infrequently reported. We reviewed the results in all patients treated for left ventricular aneurysm between 1983 and 1995 at St. Vincent Hospital and Medical Center. Of 109 patients undergoing left ventricular aneurysm surgery, 10 had open heart surgery an average of 8.9 years previously. There was no mortality or significant morbidity in those who had previous operations. Functional status improved significantly after surgery. We concluded that surgical treatment of left ventricular aneurysm in patients who had previous open heart surgery can be performed with acceptable risks and leads to functional improvement.
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INTRODUCTION
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Cooley and colleagues1 described resection of post-infarction left ventricular aneurysm (LVA) under cardiopulmonary bypass (CPB) in 1958. The operative technique for LVA resection with linear repair remained almost unchanged for nearly three decades. A major disadvantage of this conventional repair is that the lateral and medial (septal) walls of the left ventricle are sutured together at a point where they would naturally lie several centimeters apart. When the importance of left ventricular geometry was realized, it became the driving force to find new ways to manage LVA. The concept of left ventricular reconstruction in patients with chronic LVA was introduced by Jatene.2 Restoration of left ventricular geometry is now considered the cornerstone of all techniques employed to repair LVA. It is essential in order to optimize left ventricular function and consequently improve the quality of life for these patients. Left ventricular aneurysm occurring in patients who have undergone previous cardiac surgery is infrequently reported. To assess the effect of previous open heart surgery on outcome, we reviewed all patients treated for LVA between 1983 and 1995 at St. Vincent Hospital and Medical Center.
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PATIENTS AND METHODS
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Of 109 patients with documented LVA who were operated on between 1983 and 1995, 10 had previously undergone coronary artery bypass surgery. In the years following their initial surgery, they developed cardiac events that led to the formation of LVA. They underwent LVA resection with or without myocardial revascularization and other cardiac procedures. Left ventricular aneurysm was defined as a well-delineated transmural fibrous scar virtually devoid of muscle, protruding from the expected contour of the ventricular chamber, usually displaying dyskinetic motion or appearing akinetic on a left ventriculogram. The presence of LVA was confirmed at surgery in all patients. Their data were retrieved from the medical records.
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RESULTS
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There were 8 men and 2 women who had undergone at least one previous operation for myocardial revascularization; 40% of them had more than one open heart procedure prior to LVA surgery. Their mean age was 61 years, with a range of 45 to 73 years. The mean period between the last open heart surgery and the development of LVA was 8.9 years. Cardiac catheterization was performed preoperatively in all patients. The left main coronary artery was free of disease in all of them, while the left anterior descending artery (LAD) was totally occluded in 90% of patients, and diffusely diseased in one patient. The right coronary artery (RCA) was diffusely diseased in 4 patients, occluded in 4, and free of disease in 2. The circumflex or its branches were diseased in 60%. Electrophysiological studies were obtained in 2 patients and revealed easily inducible sustained ventricular tachycardia in only one. All internal thoracic artery and obtuse marginal vein grafts were patent. The mean preoperative cardiac index was 2.2 L–1·min–1·m–2. The mean left ventricular end-diastolic pressure was 23 mm Hg, and the global ejection fraction was 35.3% ± 7.9%. Only one patient was admitted with acute myocardial infarction. All patients had at least one documented myocardial infarction, and 2 had more than one. One patient had a Vineberg procedure in the past, and 70% of patients had previously received a saphenous vein graft to the LAD. Only 2 had a left internal thoracic artery graft to the LAD in their previous surgery. The first diagonal branch had a vein graft in one patient, the RCA was grafted in 4, and the posterior descending artery was grafted in one. The first obtuse marginal was grafted in 40% of this group. Angina was by far the most common indication, being present in half the group, 3 had congestive heart failure, and 2 had ventricular tachycardia. Associated conditions included diabetes mellitus in 2 patients and systemic hypertension in 2. The majority of patients (60%) were in New York Heart Association (NYHA) functional class III IV and the others were judged to be in class II.
The location of the aneurysm documented at surgery was anterolateral in 6 patients, apical in 4, and inferobasal in one. In one patient, the LVA was found to be calcified. The LVA was excised in 9 patients and plicated in one. Subendocardial resection and a cryoprobe were utilized in one patient after endocardial sites were mapped by programmed stimulation under normothermic CPB. In the other patient who had ventricular tachycardia and angina, but a negative electrophysiological study, subendocardial resection along with grafting to the appropriate vessels was carried out. Left ventricular aneurysm resection and concomitant myocardial revascularization were performed in 7 patients. The procedures included a left internal thoracic artery-to-LAD graft in one, and a vein graft to the LAD in another. The first diagonal was grafted in 2 patients, the obtuse marginal and posterior descending artery were grafted in another. The RCA was grafted in 3 patients. At surgery, a thrombus was found in the left ventricle in 2 patients. There were no ventricular septal defects. Left ventricular aneurysm resection without revascularization was performed in 3 patients whose grafts were patent and did not need any additional revascularization. The mean aortic cross clamp time was 13 min. The mean CPB time was 124.4 min. Hypothermic fibrillatory arrest without aortic cross clamping was utilized during resection and repair of LVA. This allows continuous coronary perfusion and maintains aortic valve competence, thus reducing systemic embolization of air or debris. Aortic cross clamping was restricted to the period of distal coronary anastomosis. To prevent dislodgment of thrombotic material into the systemic circulation, dissection and manipulation of the LVA was avoided prior to hypothermic fibrillatory arrest. After the heart was dissected free, a longitudinal incision was made through the aneurysmal wall. Thrombi were carefully removed. Preserving the left ventricular geometric configuration following excision of the LVA was the major concern. This was accomplished by Dor reconstruction.3,4 Inotropics and an intra-aortic balloon pump were needed in one patient; the others came off CPB without any difficulty and maintained good hemodynamics.
Two patients developed transient neurological problems that resolved before discharge. One patient remained in some degree of congestive heart failure but with improvement over his preoperative status. There were no deaths or other significant complications. Mean hospital stay was 13 days. NYHA functional status was determined 6 to 8 weeks after discharge. Improvement in NYHA class was seen in all patients. The mean preoperative NYHA class was 3.0 ± 0.7 and it improved significantly to 2.3 ± 0.5 postoperatively. Over more than 5 years of follow-up, 2 patients needed hospitalization for cardiac events: one was admitted with congestive heart failure that was treated medically, and the other needed angioplasty on two occasions: once for the LAD graft, and later for the RCA graft. All other grafts were found to be patent in both patients.
The other 99 patients who had LVA but no previous open heart procedure were also surgically treated. The majority of these patients had an uneventful postoperative convalescence. An intra-aortic balloon pump was needed in 22 (22%) patients in the immediate postoperative period to help come off CPB. Balloon pump support was withdrawn at 48 to 72 hours postoperatively. A left ventricular assist device was used in only one patient. Twelve (12%) patients required some form of inotropic support to come off CPB. There were 3 deaths in this group (mortality rate, 3%).
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DISCUSSION
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With improved treatment of patients with acute myocardial infarction and the advent of thrombolytic therapy that has reduced the prevalence of a permanently occluded LAD, the number of patients with LVA seen clinically is steadily declining. The modest number in this series is a reflection of this. A strong predictor of LVA formation is total occlusion of the proximal LAD in the absence of collaterals.5 Ventricular wall tension increases as the ventricle dilates (Laplace’s law), thus promoting further ventricular dilatation. The experience in these patients demonstrates that surgical treatment of LVA can be accomplished in spite of previous cardiac procedures that would make re-operation hazardous, especially as some patients had patent internal thoracic artery grafts. With care, it was possible to re-enter the mediastinum without injury to the internal thoracic arteries or vein grafts. Previous heart surgery is a well-recognized risk factor in LVA resection.6,7 The addition of myocardial revascularization to LVA resection in patients with multivessel coronary artery disease reduces the operative mortality and increases long-term survival.8
Left ventricular aneurysm occurring years after cardiac surgery is not well documented. Most studies do not specifically address this group of patients. The report by Cooley and colleagues9 describing intracavitary repair of LVA included both patients who had myocardial infarction within 30 days before surgery and those who had undergone previous cardiac surgery. Their conclusions are thus not specific to those who had previous cardiac surgery. Our findings support those of other studies that found a much higher incidence of angina as the main indication for operation.10–12 The goal of surgery is to improve survival and quality of life by relieving symptoms. The aim is to reduce the end-diastolic volume of the left ventricle, and this is achieved surgically by removal of the LVA. Symptomatic relief occurred in all of our patients; angina was completely relieved. In addition, 90% of patients followed up maintained normal activities. Thus, surgery provides long-term survival benefits and relief of symptoms for those who develop LVA after previous cardiac procedures, provided coronary artery bypass is carried out concomitantly when needed.
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ACKNOWLEDGMENTS
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We would like to thank the Medical Records staff at St. Vincent Hospital and Medical Center, Portland, Oregon, for their help in retrieving the data.
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REFERENCES
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ABSTRACT
INTRODUCTION
