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Asian Cardiovasc Thorac Ann 1999;7:74-75
© 1999 Asia Publishing EXchange Pte Ltd

HOW TO DO IT

An Alternative Technique for the Repair of Left Ventricular Aneurysm

Toshihiko Saga, MD, PhD, Takashi Miyamoto, MD, PhD

Department of Thoracic & Cardiovascular Surgery Hyogo College of Medicine Hyogo, Japan
For reprint information contact: Toshihiko Saga, MD, PhD Tel: 81 798 45 6851 Fax: 81 798 45 6853 Department of Thoracic and Cardiovascular Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan.

   Abstract
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 Abstract
Introduction
 Technique
 Discussion
 References
 
We describe a technique to repair a left ventricular aneurysm involving the ventricular septum. This technique can reconstruct the ventricular septum as well as the left ventricular free wall, preventing disturbances of the ventricular architecture. The technique also provides the opportunity to revascularize the ventricular septum.


   Introduction
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 Abstract
 Introduction
Technique
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Left ventricular aneurysm resection is one of the standard procedures for the treatment of complications of myocardial infarction. However, when a left ventricular aneurysm extends into the ventricular septum, there can be a residual aneurysm in the ventricular septum left untreated by classic aneurysmectomy. In such cases, we have applied a novel technique that excludes the ventricular septal aneurysm by resecting the aneurysm in the left ventricular free wall and inserting the native normal left ventricular wall into the ventricular septum.


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The left internal thoracic artery and saphenous vein were harvested for concomitant myocardial revascularization when indicated, before initiating extracorporeal cir-culation. The technique was performed under standard cardiopulmonary bypass and cardiac arrest with myocardial protection by blood cardioplegia. The left ventricular aneurysm was incised and aneurysmal extension to ventricular septum was recognized (Figure 1AGo). The aneurysm of the left ventricular free wall was then resected. During resection, care was taken to leave a width of 8 to 10 mm of nonseptal aneurysmal wall adjacent to the left anterior descending artery to facilitate reconstruction of the left ventricular free wall and myocardial revascularization to the left anterior descending artery (Figure 1BGo). The edge of the ventricular wall on the lateral side was sutured to the ventricular septum below the scarred area, along its boundary with the adjacent unscarred tissue, using continuous 3/0 polypropylene sutures to exclude the ventricular septal aneurysm (Figure 1CGo). The edge of the ventricular wall on the other side was then sutured to the normal left ventricular free wall with 3/0 polypropylene sutures to wrap the anterior wall, which excludes the septal aneurysm (Figure 1DGo). After the repair was completed, concomitant myocardial revascularization was performed. This technique was successfully applied in two patients, each with an old myocardial infarction and an anteroseptal left ventricular aneurysm.



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  		Figure 1. (A) Left ventricular aneurysm involving the ventricular septum. (B) The aneurysm of the left ventricular free wall is resected leaving an 8 to 10 mm width of the aneurysmal wall adjacent to the left descending artery (black arrow). (C) The edge of the free wall is sutured to the ventricular septum along the boundary of normal muscle and scar tissue. (D) The other edge of the wall is sutured to the normal ventricular free wall.

 

   Discussion
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In the classic surgical technique, the left ventricular aneurysm is removed and repaired by a long linear suture.1 However, when the aneurysm involves the ventricular septum, it appears that the septal portion of the lesion remains untreated. When more radical resection and suturing are applied to exclude the ventricular septal aneurysm, the architecture of the left ventricle is highly disturbed and the left anterior descending coronary artery may be sacrificed, potentially precluding revascularization of the ventricular septum.2 Alternative techniques have been proposed to treat the infarcted ventricular septum and avoid the problems described above.3,4 The principle of these techniques involves left ventricular remodeling consisting of resection of the aneurysm and insertion of a small patch to exclude the aneurysm of the ventricular septum and reconstruct the left ventricular free wall. While these techniques have proven to be effective, disadvantages persist. These techniques typically utilize a prosthetic patch and akinetic regions associated with the patch have been observed.

Stoney and colleagues5 and Cooley1 have reported wrapping techniques similar to our method. However in their techniques, the left anterior descending artery and the septal arteries are completely sacrificed with potential disturbance of the left and right ventricular architecture.

In our technique, the aneurysm of the left ventricular free wall is extensively resected and the aneurysmal section of the ventricular septum is excluded by contractile left ventricular free wall tissue, without the use of any prosthetic materials. This permits favorable reconstruction of the ventricle with minimal residual akinesis and without serious disturbance of the left ventricular architecture. This technique also provides the opportunity to re-vascularize the ventricular septum by preserving the left anterior descending coronary artery that can be grafted.


   References
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 Abstract
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 References
 

  1. Cooley DA. Repair of postinfarction ventricular aneurysm. In: Techniques in cardiac surgery. 2nd ed. Philadelphia: Saunders, 1984:240–5.

  2. Hutchins GM, Brawley RK. The influence of cardiac geometry on the results of ventricular aneurysm repair. Am J Pathol 1980;99:221–30.[Abstract]

  3. Jatene AD. Left ventricular aneurysmectomy, resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321–31.[Medline]

  4. Dor V, Saab M, Coste M, Kornaszewska M, Nontiglio F. Left ventricular aneurysm: a new surgical approach. Thorac Cardiovasc Surgeon 1989;37:11–9.[Medline]

  5. Stoney WS, Alford WC, Burrus GR, Thomas CS Jr. Repair of anteroseptal ventricular aneurysm. Ann Thorac Surg 1973;15:394–404.[Medline]




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This Article
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Takashi Miyamoto
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