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Eur J Cardiothorac Surg 2005;27:210-215
© 2005 Elsevier Science NL

Left ventricular aneurysms: early and long-term results of two types of repair

Coimbra University Hospital, Coimbra P-3000, Portugal

Received 4 October 2004; received in revised form 5 November 2004; accepted 17 November 2004.

^* Corresponding author. Tel.: +351 39 400 418; fax: +351 39 829 674. (E-mail: antunes.cct.huc{at}mail.telepac.pt).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 
Objective: Controversy still exists regarding the optimal surgical technique for postinfarction left ventricular (LV) aneurysm repair. We analyze the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LV aneurysms. Methods: Between May 1988 and December 2001, 110 consecutive patients underwent repair of LV aneurysms. These represent 2.0% of a total group of 5429 patients who underwent isolated CABG during the period. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to patch remodelling. There were 94 (84.5%) men and 17 women, with a mean age of 59.2±9.2 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 2.7±0.8) and 14 (12.7%) had associated coronary endarterectomy. Forty-four (40.0%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.2% in both groups). Left ventricular dysfunction (EF>40%) was present in 72 (65.5%) patients (linear 61.8%, patch 73.5%, NS). Results: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. During a mean follow-up of 7.3±3.4 years (range 4–182 months) 14 patients (14.3%) had died, 12 (85.7%) of possible cardiac-related cause. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. There was no significant difference in late survival between the patch and the linear groups. At late follow-up the mean angina and NYHA class were, 1.3 (preoperative 2.4, P<0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups. There was no significant difference in hospital readmissions for cardiac causes (linear 22.8% and patch 37.0%). Conclusions: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Both techniques achieved good results with respect to perioperative mortality, late functional status and survival.

Key Words: Left ventricular aneurysm • Linear repair • Patch repair

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 
Left ventricular aneurysms (LV aneurysms) are a common complication of myocardial infarction. The scarred area becomes increasingly thin and dyskinetic. The aneurysm absorbs part of the LV ejection, eventually leading to cardiac failure which may be refractory to medical therapy and require surgical treatment.

Surgical methods to restore the volume and shape of the left ventricle have evolved over the years. Surgical repair of LV aneurysms was first performed by Charles Bailey [1]. The first resection under cardiopulmonary bypass was reported by Denton Cooley and associates [2]. During the following decades, besides the traditional linear repair, newer patch remodeling techniques were devised and reported in an effort to improve results [3–6]. Although aneurysmectomy has been performed for almost five decades, the most appropriate surgical approach to a patient with a dyskinetic LV aneurysm is still controversial.

In this retrospective study we assess the early and late results of patients undergoing surgery by two techniques of repair of postinfarction dyskinetic LV aneurysms, namely patch remodeling and linear repair.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 
2.1. Patient population
From May 1988 to December 2001, 5429 consecutive patients were subjected to CABG. Of these, 110 (2.0%) underwent surgical repair of postinfarction dyskinetic LV aneurysms. All patients had simultaneous coronary revascularization. Patients who had other associated procedures (e.g. valve surgery) are not included, to avoid eventual confounding factors. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to pacth repair. The diagnosis of LV aneurysms was made preoperatively by the angiographic appearance (paradoxical motion), and confirmed intraoperatively. The indication for surgery in patients with normal or moderately impaired LV function and low functional NYHA class was based on their coronary artery disease and angina class. In these cases, LV scars that clearly contained little muscle and were of important size, encountered during surgery for coronary artery disease, were excised.

Demographic, clinical, operative and perioperative, and in-hospital outcome data were collected prospectively and entered into a computerized database especially designed for patients receiving coronary revascularization procedures in our department. The variables selected for analysis were the following:

(1) preoperative—age, sex, body surface area, cerebral vascular disease, peripheral vascular disease, diabetes mellitus, history of hypertension, angina class (CCS, Canadian Cardiovascular Society), functional status (NYHA, New York Heart Association), reoperation, recent myocardial infarction, surgical priority (elective, urgent or emergent), number of vessels diseased, left main disease, left ventricular function (assessed by ventriculography or echocardiography or both);

(2) operative—type of repair (linear or patch), cardiopulmonary bypass time, number of grafts, coronary endarterectomy, use of double internal thoracic artery (ITA);

(3) postoperative—perioperative mortality, use of inotropic agents, use of mechanical assist, reoperation for bleeding or sternal complications, respiratory failure, acute renal failure, myocardial infarction, cerebrovascular accident, and length of hospital stay.

The definitions of some of these variables are indicated in Appendix A.

2.2. Preoperative clinical and angiographic data
Perioperative, clinical and angiographic data are detailed in Table 1. There were 93 male (68 linear, 28 patch, P<0.001) and 17 women (eight linear, nine patch). The mean age was 59.2±9.2 years (range 37–75 years) with no difference between the two groups. Seventeen (15.5%) patients were diabetic, and 62 (56.4%) had hypertension. Forty-four patients (40%) were in Canadian Cardiovascular Society (CCS) class III or IV and 13 (11.8%) were in NYHA functional class III or IV. Three-vessel disease was present in 83 patients (79.0%), 27 patients (20.0%) had double-vessel coronary disease, and 16 (14.5%) had left main disease. There was only one case (in the linear group) of redo-CABG among these patients. All patients had had at least one myocardial infarction (MI) and only two patients had history of recent MI (one linear, one patch). Eighty-five (77.3%) aneurysms were anterior with no significant difference between the two groups. Left ventricular dysfunction (EF<40%) was present in 65.5% (47 linear, 25 patch, NS). The majority (91.8%) of patients were operated on electively. No patient in our series had experienced embolic episodes from the aneurysm and none had implantable cardioverter defibrillators (ICDs) preoperatively.

Depending on the size and shape of the left ventricular cavity, a portion of the thinned wall was resected. For the linear repair, depending on the consistency of the LV wall, the edges were either sutured directly (overlaping technique) or with two strips of Teflon using a combination of continuous and mattress sutures. For patch repair, the aneurysm was opened and an elliptical or circunferential patch of Teflon, covered on the ventricular side by autologous pericardium, was sutured to the ‘red/white’ border zone of the ventricular wall and septum, using a continuous 4-0 polypropylene suture. The excess aneurysm wall was resected, leaving a residual portion that was closed over the patch using a continuous 3-0 polypropylene suture. Endocardial mapping was not performed.

Once ventricular repair was completed, bypass grafting was carried out. Revascularization, including the area of LV aneurysm repair, was performed whenever indicated and technically possible.

2.4. Follow-up
Follow-up data were obtained directly from the patients and/or their general practitioners by telephone call or a written questionnaire. Data obtained included survival, functional status (NYHA) and angina class (CCS), and cardiac-related hospital readmission. Twelve patients (10.9%) were lost to follow-up because of migration or unknown reasons.

2.5. Statistical analysis
Data were retrieved from the database and were retrospectively analyzed with assistance of the Systat^© statistical software. Continuous variables are expressed as mean±SD. Categorical variables are presented as percentages. Groups were compared with use of Fischer's exact test, Student's t-test or the Mann–Whitney U-test, as appropriate. Survival curves were calculated according to the method of Kaplan and Meier and subgroups were compared using the Log-rank test (method of Breslow–Ghean).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 
3.1. Intraoperative data (Table 3)
The mean cardiopulmonary bypass time was 82.7±33.9min with no significant difference between the two groups. Concomitant myocardial revascularization was performed in all patients. The left anterior descending artery was revascularized in 102 (93%) patients, predominantly (92.2%) with ITA (91 left, 3 right). ITA grafts were used in 105 (95.5%) patients for a mean of 1.2±0.6 arterial anastomoses per patient (1.3±0.6 linear, 1.0±0.5 patch, P=0.011). The left ITA was used in 105 patients (99% linear, 88% patch, P=0.015). In 26 patients (23.6%) both left and right ITAs were used (29% linear, 6% patch, P=0.050). Additionally, a mean of 1.5±0.8 venous anastomoses per patient were constructed. Endarterectomies were performed in 14 cases (12.7%).

The cumulative survival for the entire group is shown in Fig. 1. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. Ten-year survival was 84.6% in the pacth group and 79.7% in the linear group. However, comparison of survival curves between the two groups revealed no significant difference (Fig. 2).

View larger version (18K): [in this window] [in a new window]   Fig. 1. Cumulative survival for the entire group of patients.

View larger version (20K): [in this window] [in a new window]   Fig. 2. Cumulative survival for patients with pacth (dashed line) or linear repair (continuous line), showing no significant difference (P=0.6) between the two groups (Log-rank test). Numbers of patients at risk for each time-interval are indicated at the bottom.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 
Repair of postischemic left ventricular aneurysms goes back to 1954 when Bailey successfully performed the first left ventricular aneurysmectomy with the help of a partially occluding, side-biting clamp on a beating heart [1]. In 1958, Cooley [2] first performed left ventricular aneurysmectomy by plication and linear closure under extracorporeal circulation. Subsequently, the philosophy of regaining the normal left ventricular geometry led to surgical methods aimed at restoration of the elliptical shape of the left ventricle. These include excision, plication, septoplasty/plication, and overlap techniques, grossly classified as linear repair, or patch repair methods.

In the linear repair the usual technique is direct suture of the two edges. When reconstruction is performed with this technique, a line of closure is selected that will least distort the LV. The edges are either sutured directly or supported by two strips of Teflon. Alternatively, the aneurysm can be repaired using an overlap technique or by a modified linear technique, eventually combined with septoplasty.

As for the patch repair there are two main techniques: the circular patch and the endoventricular patch. Identical versions of the latter have been termed endoaneurysmorrhaphy by Cooley [5] or endoventricular circular pacth plasty repair by Dor [4]. The rationale for endoventricular pacth is in part based on the fact that the area of septal scarring can be excluded from the reconstructed LV which is also remodeled and/or resized appropriately.

Although these and other surgical methods have evolved over last decade and a half, the most appropriate surgical approach to the treatment of dyskinetic LV aneurysms is still controversial. On purely theoretic considerations [9–11], patch remodeling of postinfarction LV aneurysms improves ventricular geometry, thus contributing to better early and late outcome [12–14]. But some retrospective clinical studies failed to demonstrate any difference between linear and patch repairs [15–20].

In this study, we compared the early and late results of 110 consecutive patients undergoing repair of postinfarction dyskinetic LV aneurysms non-randomly assigned to either linear or patch repair. All procedures were performed by the same surgeon and there was no difference in the intraoperative management with regard to the myocardial protection strategy. Another limitation for this comparison lies in the fact that the preoperative cardiac status of the two groups was not identical. Generally, the choice of the repair technique depended on factors such as localization, size and extension of the scar. An extensive and clearly defined fibrotic globoid aneurysm sac with a well formed neck, especially when located in the or near the apical area, generally led to patch repair, while in a wide-based dyskinetic segment imprecisely separated from the surrounding viable myocardium a linear repair was usually preferred. Hence, it can be speculated that patients operated on by the linear technique could be expected to have better preoperative cardiac status and, thus, a better immediate outcome and late survival should have been expected in this group. Therefore, the following comments must be considered with this in mind.

In this study there was no perioperative mortality. This result, that compares favorably with other recently published studies [12–14,16–21], where the reported hospital mortality ranged from 2 to 8%, could be attributed, at least in part, to differences between patient populations. In fact, some of those studies include patients in more advanced NHYA class and LV dysfunction and cases with concomitant mitral valve surgery. All these constitute established risk factors for hospital mortality. It is precisely for this reason that in the last decade we followed a strict policy of preoperative modulation of modifiable risk factors, such as functional class. Even LV function can be clearly bettered by aggressive anti-failure therapy. We feel very confident that this policy became life-saving for many patients. For argument sake, the mortality for isolated CABG during this period was 1.2%.

The most common in-hospital complications found in this study were low cardiac output (20.9%), ventricular arrhythmias (4.5%), stroke (5.5%) and bleeding (4.5%), and there were not significant differences between the linear and patch groups. These results are comparable to those reported by other authors [16,17,22].

The 5-year survival in our patients (91.3%) also compares favourably with those reported in recent series, between 73 and 90% [12–21]. Again, as was the case with early results, the late results are variable, and largely dependent on the differences in patient populations.

As others have found [13,16,17,19,21,23], we have demonstrated a significant improvement in the angina class after operation (from 2.4 to 1.3). By other hand the mean NYHA class remained basically unaltered as we could find only a small change (from 1.7 to 1.5).

In conclusion, the controversy regarding whether patch repair provides results superior to those achieved with the more classical linear closures is likely to remain unanswered. We are unaware of any prospective studies comparing the results of the two procedures, but several studies [12–14] showed improved early and/or late results with patch techniques, while others [15–20] reported no differences between linear and patch repairs. In our experience, we could not demonstrate significant differences either in the early or in the late results between the two techniques, possibly also because the groups are different and the patients were not really the sickest ones, especially with regard to the condition of the remote myocardium.

We believe that the technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Although this study is retrospective and the patients in the two groups were not entirely similar, both patch and linear repair achieved good results with respect to perioperative mortality, late functional status and survival.

	Appendix A

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 

	Appendix B. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

Dr Antunes: I stress two points. First, the global mortality for the more tan 4000 patients who had isolated coronary surgery during this period was 1.0. So the fact that we had zero mortality in this case, it is just a statistical fact. But on the other hand, it is important, and I didn't stress that well enough, this study excludes all patients who had all other types of pathology; no valves, no valve involvement, no valve repairs. These were just patients whose only factor was the presence of an aneurysm.

Dr R. Deac (Mures, Romania): For years we were looking for a technique to repair a left ventricular aneurysm. My question is what were the criteria by which you assigned patient to linear or to patch reconstruction in your study?

Dr Antunes: All these operations were done by the same surgeon, that is myself, and basically it is a decision of the moment. The feeling is that if the aneurysm is more apical, therefore the longitudinal diameter of the ventricle is longer, then a patch repair is probably more likely to restore the shape of the ventricle.

If, on the other hand, you have either a lateral or a posterior aneurysm, then the linear repair appears to be more logical, and that is what we did. That is, we do not have a specific rule of thumb to decide when to do one or the other. And this was a conclusion that was surprising to me because I tended to believe that we should do more and more the Dor type procedure, and these results do not lead to that conclusion.

Dr J. Dinkhuysen (San Paulo, Brazil): I would like to know if you revascularized the artery of the infarct which promoted the aneurysm of the ventricle?

Dr Antunes: We tended not to, except for the anterior descending artery. That artery, if it is still patent, we will do our best to revascularize. That is exactly the opposite for the posterior descending artery. Usually, it is a fibrous cord and then we tend not to complicate the procedure by doing the graft of that artery.

Dr T. Wahlers (Jena, Germany): Don't you think that the assessment by echo determining endsystolic volume after remodeling might help you in the future to assess whether this or that procedure might be more advantageous in the specific patient?

Dr Antunes: You must realize that this was just a retrospective observational study on prospectively collected data. The results surprised us, and we will have to re-analyze each individual patient and see whether we can find any anatomical factor that in fact influences these results. It is a matter for thought in the near future in our unit.

	Footnotes

 
Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A Appendix B. Conference... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pedro E. Antunes Manuel J. Antunes Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Antunes, P. E. Articles by Antunes, M. J. Search for Related Content PubMed PubMed Citation Articles by Antunes, P. E. Articles by Antunes, M. J. Related Collections Cardiac - other Coronary disease Myocardial infarction