Asian Cardiovasc Thorac Ann 2000;8:311-314
© 2000 Asia Publishing EXchange Pte Ltd
Endoventricular Left Ventriculoplasty: Overlap Technique for Akinetic Scar
Masaru Sawazaki, MD,
Toshiaki Ito, MD,1,
Kenzo Yasuura, MD,
Yutaka Ogawa, MD,
Shin-ichi Mizutani, MD,
Hiroshi Ishikawa, MD,
Ayuko Miura, MD,
Ryotaro Hashizume, MD
Division of Thoracic Surgery
Komaki City Hospital
Aichi, Japan
1 Department of Surgery
Nagoya 1st Red Cross Hospital
Nagoya, Japan
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For reprint information contact: Masaru Sawazaki, MD Tel: 81 568 76 4131 Fax: 81 568 76 4145 email: sawamasa{at}lemon.plala.or.jp Division of Thoracic Surgery, Komaki City Hospital, 1-20 Jhobushi Komaki-city, Aichi 485-0044, Japan.
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Abstract
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Four patients were treated by endoventricular left ventriculoplasty with coronary artery bypass grafting. Three were elective cases and one had acute myocardial infarction. The overlap technique of left ventriculoplasty was employed in the 3 elective cases. An endoventricular circular suture was placed on the perimeter of the scar, the lateral free margin of the incision was sutured to the septum directly, and the margin of the septal side overlapped the anterior wall. In these 3 cases, end-diastolic volume index and end-systolic volume index were decreased and ejection fraction was increased postoperatively. It was concluded that coronary grafting combined with left ventriculoplasty using the overlap method was suitable for patients with ischemic heart disease and an akinetic scar.
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Introduction
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In some cases of ischemic heart disease with postinfarction anteroseptal akinetic scar, we have adopted simple coronary artery bypass grafting (CABG). Complaints associated with heart failure, such as shortness of breath on effort or orthopnea, may disappear after CABG. However, in most cases, left ventricular wall motion is not sufficiently improved. Dor and colleagues1 reported the efficacy of left ventricular patch plasty not only in dyskinetic scars but also in akinetic scars. Surgery for left ventricular aneurysm was reported by Cooley and colleagues2 in 1958. Modifications have been introduced to improve the performance of the left ventricle, including septal plication, circular suturing of the opening, and endoventricular circular patch plasty.3–5 An alternative method, termed the overlap technique, has also been reported.6,7 After incising the akinetic scar, the left border of the incision is sutured to the septum and the other border is sutured to the anterolateral wall of the left ventricle to exclude the akinetic zone of the interventricular septum. We selected Dor's endoventricular circular suture without patch plasty and excluded the septum by the overlap technique in elective cases.5–7
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Patients and Methods
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Between August and December 1998, 4 patients were treated by endoventricular plasty and CABG. Three of these patients had a history of old anteroseptal myocardial infarction and were suffering from congestive heart failure and angina pectoris. Two were in New York Heart Association (NYHA) functional class II and one was in class III. Coronary angiograms showed significant stenotic lesions involving the left anterior descending artery (LAD). Left ventriculograms revealed large anteroseptal akinetic scars. End-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) were measured in left ventriculograms in the right anterior oblique view. Patient characteristics are listed in Table 1
. The fourth patient had acute myocardial infarction and severe congestive heart failure (NYHA class V). Her coronary angiogram showed triple-vessel disease including obstruction of the LAD at segment 6. Echocardiography revealed dyskinesis of the anteroseptal lesion. Because she was in the acute phase of myocardial infarction in which the aneurysmal wall would be fragile, Dor's original endoventricular patch plasty was selected for this patient.1
Cardiopulmonary bypass was established with aortic perfusion, two-stage drainage from the right atrium, and venting of the left ventricle under normothermia. Cold blood cardioplegia was given antegradely and retrogradely every 20 minutes, and terminal warm blood cardioplegia was infused retrogradely before declamping the aorta. CABG was performed first. In the 3 elective cases, radial artery was selected for grafting the circumflex arteries and the diagonal branch, right gastroepiploic artery was anastomosed to the right coronary artery. In the emergency case, the circumflex artery and the right coronary artery were bypassed using saphenous vein grafts. The LAD which supplied the region that included the infarcted scar, was revascularized with left internal thoracic artery. The left ventricle was incised longitudinally at approximately 1 cm lateral to the LAD via the apex to the inferior wall (Figure 1A). In an akinetic scar, the border between scarred and normal muscle is not so clearly defined as in dyskinetic aneurysms.1 Therefore, the anterior half of the interventricular septum and the anterolateral wall on the right side of the anterior papillary muscle should be excluded. An endoventricular circular suture was placed on this line using 3/0 polypropylene monofilament suture (Figure 1B). The diameter of the suture line was shortened from between 50 and 60 mm to between 20 and 30 mm. The lateral free margin of the incision was sutured directly to the septum at the level of the circular suture with 3/0 monofilament continuous running over-and-over suture (Figure 1C). The margin on the septal side was made to overlap the anterior wall and sutured to it directly (Figure 1D).
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Figure 1. Overlap technique of left ventriculoplasty (d1 and d2 are the diameters before and after endoventricular circular suturing).
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Results
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All 4 patients survived and were in NYHA functional class I postoperatively. The numbers of distal anastomosis were 4, 2, 5, and 4, for patients 1 to 4, respectively. All of these grafts were patent with no stenosis. Cryotherapy was not needed because none of the patients had ventricular arrhythmias. Other operative and postoperative findings are given in Table 2. Case 1 had the largest left ventricle, the improvement in volume and function is illustrated in Figure 2; wall motion in segments 2 and 3 improved postoperatively. The other 2 patients who had elective surgery showed similar improvements. All 4 patients have been doing well without any cardiac events for more than one year after the operation.
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Figure 2. Left ventriculograms of case 1. Left ventricular volumes were reduced and contractility improved postoperatively. EDVI = end-diastolic volume index, EF = ejection fraction, ESVI = end-systolic volume index.
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Discussion
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In cases of akinetic scar, EF has been reported to increase from 23% ± 5% to 38% ± 11% after endoventricular patch plasty.1 In our limited number of cases, left ventricular wall motion was improved by endoventricular left ventriculoplasty combined with CABG. In considering whether a patch is necessary for this type of ventriculo-plasty, it should be remembered that akinetic or dyskinetic scars are old postinfarction tissue that includes fibrous tissue strong enough to be used for the plastic surgery. Stoney and colleagues6 and Guilmet and colleagues7 described ventriculoplasty using the aneurysmal wall and excluding the anterior part of the interventricular septum. We consider that a patch is needed in the acute phase postinfarction of the left ventricle because the infarcted tissue is fragile. This is similar to a postinfarction ven-tricular septal defect treated by the infarction exclusion technique.8 Thus, patch plasty was selected for the case of acute myocardial infarction but the elective cases with akinetic scar were treated by the overlap method. Because an old akinetic scar includes some muscle fibers that have not been able to contract against the wall stress, it was hoped that overlapping the akinetic wall might achieve more contractility. After volume reduction surgery, wall stress should decrease according to Laplace's law.9 Therefore, an overlapped akinetic wall might function after ventriculoplasty. However, it could not be determined from our limited experience whether the overlap method is superior to patch plasty.
As to whether the LAD should be revascularized, Stoney and colleagues6 did not perform CABG. In the overlap method used in this study, the septal side of the incision line was sutured to the anterolateral wall so as not to injure the LAD. The LAD was grafted to supply the remaining muscle in this area. When circular suturing the border between the scarred and normal muscle, a major consideration is how much the diameter of the suture line should be shortened (Figure 3). In this series, we reduced the enlarged left ventricle to normal size. As wall motion improved in the LAD area, we recommend that the dimensions of the left ventricle should be normalized. The indication for this type of ventriculoplasty in patients with akinetic scars is difficult to decide. Dor mentioned that ventricular reconstruction can be recommended for all cases of ventricular aneurysm or akinesia with angina, arrhythmia, or attacks of cardiac insufficiency, when there is a global EF > 30% and contractile EF > 40%.10 In this category of patient, the operative mortality rate varies from 1.5% to 3%.
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Figure 3. How much should the diameter of the suture line be shortened? The short-axis diameter (2r) of the normal left ventricle at the level of the base of the papillary muscle is approximately 25 to 35 mm. The LAD perfuses almost one-third of the circumference of the left ventricle. Thus, the diameter (d1) of the circular suture line (border of the LAD territory) is calculated as  3r (22 to 30 mm). The diameter (d2) of the suture line between the scar and normal muscle should be shortened to "d1" to maintain the normal dimension of the left ventricle and to prevent the left ventricular volume from becoming too small. LAD = left anterior descending coronary artery, LCX = left circumflex artery, RCA = right coronary artery.
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It was concluded that Dor's endoventricular patch plasty and associated CABG can be useful in patients with dyskinetic or akinetic scars. However, the patch is not always necessary in elective cases because scar tissue is available to reconstruct the left ventricle by the overlap method.
Presented at the 7th Annual Meeting of the Asian Society for Cardiovascular Surgery, Singapore, May 28–31, 1999.
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References
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Dor V, Sabitier M, Di Donato M, Montiglio F, Toso A, Maioli M. Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars. J Thorac Cardiovasc Surg 1998;116:50–9.[Abstract/Free Full Text]
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Cooley DA, Collins HA, Morris GC Jr, Chapman DW. Ventricular aneurysm after myocardial infarction: surgical excision with use of temporary cardiopulmonary bypass. JAMA 1958;167:557–60.
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Cooley DA. Ventricular aneurysms and akinesia. Cleveland Clin Quart 1978;45:130–2.[Medline]
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Jatene AD. Left ventricular aneurysmectomy resection or reconstruction. J Thorac Cardiovasc Surg 1985;89: 321–32.[Medline]
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Dor V, Kreitmann P, Jourdan J, Acar C, Saab M, Coste P. Interest of "physiological closure" (circumferential plasty on contractile areas) of left ventricle after resection and endocardectomy for aneurysm or akinetic zone: comparison with classical technique about a series of 209 left ventricular resections. J Cardiovasc Surg 1985;26:73.
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Stoney WS, Alford WC Jr, Burrus GR, Thomas CS Jr. Repair of anteroseptal aneurysm. Ann Thorac Surg 1973; 15:394–404.[Medline]
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Guilmet D, Popoff G, Dubois C, Tawil N, Bachet J, Goudot B, et al. A new surgical technique for the treatment of left ventricular aneurysm: the overcoat aneurysmoplasty. Preliminary results. 11 cases. Arch Mal Coeur Vaiss 1984; 77:953–8. (French)[Medline]
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Komeda M, Fremes SE, David TE. Surgical repair of post- infarction ventricular septal defect. Circulation l990; 82(Suppl IV):243–7.
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Dor V, Saab M, Coste P, Sabatier M, Montiglio F. Endoventricular patch plasties with septal exclusion for repair of ischemic left ventricle: technique, results and indications from a series of 781 cases. J Jpn Thorac Cardiovasc Surg 1998;46:389–98.
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Abstract
Introduction
