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ORIGINAL ARTICLE |
Department of Cardiovascular Surgery Heart and Diabetes Center North-Rhine Westphalia Ruhr University of Bochum Bad Oeynhausen, Germany
Kasim Oguz Coskun, MD, Tel: +49 5731971916, Fax: +49 5731971961, Email: dr_coskunok{at}yahoo.de, Department of Cardiovascular Surgery, Heart and Diabetes Center North-Rhine Westphalia, University of Bochum, Georg Strasse 11, 32545 Bad Oeynhausen, Germany.
ABSTRACT
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.
Key Words: Cardiac Surgical Procedures • Heart Aneurysm • Myocardial Infarction
INTRODUCTION
Transmural scarring after myocardial infarction (MI) results in left ventricular aneurysm (LVA) in 10%–35% of patients.1,2 LVA usually develops due to infarct expansion, thinning, and dilatation of the infarct zone, along with fibrosis and impaired contractility. This pathophysiological process has been referred to as "expaneurysm".3 It may also result from MI secondary to blunt chest trauma.4 LVA may be detected as an akinetic or dyskinetic segment of the left ventricle (LV), protruding from the surrounding cardiac silhouette with clear demarcation from contractile segments on a left ventriculogram. A large LVA causes progressive LV dilatation and volume overload hypertrophy with increased wall tension in the non-infarcted region, decreased LV performance, and thrombus formation in the aneurysmal cavity.5 Ventricular arrhythmias may develop at the border between healthy and necrotic tissue, due to electrophysiological differences, causing angina or sudden death. However, the main consequences of a large LVA are LV failure, pulmonary congestive symptoms, and diminished exercise tolerance due to low cardiac output. Asymptomatic patients with normal LV end-diastolic pressure and no significant coronary disease, thrombus, or malignant arrhythmias, should be treated medically because they have a 90% survival rate at 10 years.6 Symptomatic patients on medical therapy have a 5-year survival rate of 12%–27%.1,7 Surgery improves 5-year survival to 50%–77%.1,2 The aim of this study was to compare early and late results of 2 techniques of LVA repair: classic Cooley aneurysmectomy and the Dor procedure.8,9
PATIENTS AND METHODS
Data were collected retrospectively from hospital records and the database of the Department of Cardiovascular Surgery, Heart and Diabetes Center North-Rhine Westphalia. Between 1993 and 2002, 269 consecutive patients underwent LV aneurysmectomy (Table 1
). Cineangiography and echocardiography were performed preoperatively in all patients. The main criterion for aneurysmectomy was the clinical status of the patient (New York Heart Association functional class II–III). Cooley aneurysmectomy was performed in 164 patients and the Dor procedure in 105. All patients who left hospital were followed up by examination or by information received from the referring cardiologist.
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RESULTS
Postoperative outcomes are summarized in Table 2 and 3. There were no differences in early mortality or 5-year survival between groups. Moreover, there were no differences between groups in terms of quality of life. Ninety-six patients died during the 10-year follow-up; 173 are still alive (Figure 1). Patients in both groups showed similar long-term survival, in spite of the higher frequency of extended anteroseptal infarction among those who underwent the Dor procedure. Comparison of pre- and postoperative echocardiographic findings showed a significant improvement in LV function postoperatively in both groups. Late Doppler echocardiographic studies revealed improved ejection fraction, end-diastolic and end-systolic dimensions (Table 4).
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The treatment of acute MI has improved due to primary angioplasty and stenting. These interventions have reduced complications including aneurysm development. Heart rate variability analysis is extensively used to evaluate autonomic modulation of the sinus node and identify patients at risk of aneurysm formation and increased cardiac mortality. Intensifying the medical treatment can prevent or limit the development of aneurysms. The most important prognostic factors in patients with established LVA are infarct location and myocardial function at rest. When pulmonary congestive symptoms, angina pectoris, low cardiac output, malignant arrhythmias, or embolization occur, aneurysmectomy should be performed. Viability studies such as dobutamine stress echocardiography, scintigraphy, or magnetic resonance imaging are helpful in selecting patients who could benefit from LVA surgery. Dobutamine-responsive wall thickening indicates viable myocardium in the middle and outer layers of the LV wall. More than 80% of LVA are located anterolaterally near the apex; 5%–10% are located posteriorly. LVA are often associated with total occlusion of the left anterior descending artery and poor collateral supply; 75% of patients have multivessel disease.10,11
Linear plasty according to the Cooley procedure allows wide excision of the scar area and linear closure of the LV opening within the scar, thus leaving some scar tissue. For this technique, the interventricular septum should be intact. It is advantageous in anterolateral and anteroapical aneurysms.8 In the Dor procedure, a patch is implanted inside the LV, thereby excluding the akinetic portion of the LV septum and permitting reconstruction and restoration of LV geometry.9,10 Dor plasty is effective for large anteroseptal or posterobasal aneurysms, and can be used in cases of more severe LV damage where implantation of a patch avoids inadequate LV dimensions after the operation, irrespective of whether there is dyskinesia or akinesia, facilitating better rearrangement of the myocardial fibers. It is important to identify the base of the aneurysm in this procedure.9,11
We found no significant difference in mortality between the 2 techniques. Patients undergoing the Dor procedure had a tendency towards higher hospital mortality but better 10-year survival. This group had more extended anteroseptal infarctions, and limited remaining viable myocardial tissue to cope postoperatively with the new hemodynamics. However, the myocardium recovers to a more normal LV shape after the Dor procedure, allowing myocardial fibers to rearrange and contract in a more favorable manner. There were no differences between groups in terms of clinical status as indicated by echocardiographic data. Several studies have demonstrated that clinical outcomes do not depend on the LV plasty procedure used; both LV systolic function and long-term survival improve after surgery.7,12 Cherniavsky and colleagues13 compared the results of linear plasty and patch endoventriculoplasty and found no significant difference in mortality. Komeda and colleagues14 also found no difference in mortality among various types of LVA repair. However, Hutching and Brawley15 demonstrated that mortality after aneurysmectomy with linear plasty was due to the considerable reduction and deformation of the LV cavity, on the basis of postmortem data. This could explain the tendency towards lower 10-year survival seen in our patients. We therefore recommend the Dor procedure for extensive aneurysm of apicoanterolateral segments with significant involvement of the interventricular septum, and for posterior LVA.
LVA repair was carried out together with revascularization, when indicated, in our patients. Left anterior descending coronary artery revascularization increases emetic flow through the perianeurysmatic portions of the septum and lateral wall, so contributing to improved LV function.16 Patients who benefited most from the operation were those with a more favorable postoperative contraction pattern, where ejection fraction improved, arrhythmias were eliminated, and cardiac output was restored. These patients had longer survival and better quality of life. Aneurysmectomy is contra-indicated in patients with LV ejection fraction <30%, right ventricular failure, pulmonary hypertension, grade 3 mitral insufficiency, or diffuse coronary artery disease not amenable to revascularization. In such patients, orthotropic transplant or cardiomyoplasty are alternatives to aneurysmectomy and coronary artery bypass grafting.17
It is important to note that this study had some important limitations. It was retrospective, although we had a relatively large number of patients between 1993 an 2002. The hospital mortality reflects institutional postoperative patient care. Therefore, a systematic underestimation of early mortality is likely, and hospital mortality gives an incomplete picture of the mortality. However, it was concluded that the most important aspect of LVA repair is reduction of LV volume, thereby decreasing tension on the remaining viable myocardial tissue, and diminishing myocardial oxygen consumption. Restoration of LV geometry is facilitated, especially by Dor procedure, enabling better myocardial contractility. Both types of aneurysm repair showed similar improvement in clinical and echocardiographic data postoperatively. We recommend the Dor procedure for extensive aneurysm of apicoanterolateral segments with significant interventricular septum involvement and for posterior LV aneurysms.
ACKNOWLEDGMENTS
We thank Mahmoud El-Arousy, PhD, Department of Cardiovascular Surgery, Heart and Diabetes Centre North-Rhine Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany, for his important comments on the manuscript.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:490-493
© 2009 by SAGE Publications
DOI: 10.1177/0218492309348636
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