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Eur J Cardiothorac Surg 2005;27:475-480
© 2005 Elsevier Science NL

Left ventricular dimension and shape after postinfarction aneurysm repair

A.V. Marchenko*, A.M. Cherniavsky, T.L. Volokitina, S.A. Alsov, A.M. Karaskov

Aortic and Coronary Artery Surgery Department, Research Institute of Circulation Pathology, Rechkunovskaya 15, 630055 Novosibirsk 55, Russia

Received 11 September 2004; received in revised form 2 December 2004; accepted 13 December 2004.

* Corresponding author. Tel.: +7 3832 32 47 58; fax: +7 3832 32 45 50. (E-mail: mammaria{at}mail.ru).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: We evaluated left ventricular dimensions and shape in the patients with postinfarction LV aneurysm before and after different techniques of ventricular reconstruction. Methods: From January 1997 to December 2003, 158 patients underwent LV aneurysm repair. There were 152 men and 6 women, with a mean age 50±8.4 years. Ventricular reconstruction was performed by using linear plasty of the Cooley technique in 35 patients, septal plasty of the Stoney technique—in 57 patients, and endoventriculoplasty of the Dor technique—in 66 patients. Left ventricular volumes and dimensions, global and contractile left ventricular function, diastolic sphericity were analyzed before and after operation over a period of 10 days to 5 years. Results: The EchoCG studies showed a significant postoperative improvement of the LV contracting function regardless of LV plasty technique used. The index of sphericity changed from 0.71±0.08 to 0.72±0.06 after linear plasty, from 0.71±0.05 to 0.73±0.07 after septal plasty, from 0.74±0.06 to 0.56±0.05 after endoventriculoplasty. The hospital mortality rate was 6.3%. There is no significant difference in hospital mortality rates between the different techniques of LV aneurysm repair. Conclusions: Our results show the effectiveness of different techniques of LV aneurysm repair, when the differentional approach to choice an adequate method of ventricular reconstruction was applied.

Key Words: Left ventricular aneurysm • Left ventricular geometry • Endoventriculoplasty • Linear plasty • Septal plasty


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
A modern era of surgical treatment of postinfarction aneurysms of the left ventricle (LV) started in 1958 when Cooley performed the first open aneurysm resection using a linear LV plasty with a cardiopulmonary bypass [1]. In 1973 Stoney reported on a septal technique for the reconstruction of anteroseptal aneurysms [2,3].

However, regardless of the hemodynamic effect of aneurysmectomy, unduly wide excision of the scar area and linear closure of the LV defect might lead to the deformation of the LV chamber and a reduction in LV diastolic volume. A new approach to reconstructing LV aneurysms was introduced by Jatene (1985), who took into account the geometry of the LV cavity [4]. In 1989 Dor introduced endoventriculoplasty, with a patch sutured along the interface of a scar and viable myocardium [5]. The same year Cooley proposed that the patch should be covered with the aneurysmal wall using the procedure of endoaneurysmorrhaphy introduced by Matas over a century ago [6].

Today there does not exist a generally accepted approach to the selection of the optimal method of LV plasty. Some researchers report on good short-term and long-term results after conventional linear or septal plasty of LV [7–10], while others prefer the new technique of LV reconstruction using patch endoventriculoplasty [11–14].

The purpose of this study was to evaluate a left ventricular function and geometry in the patients with postinfarction LV aneurysm before and after different techniques of ventricular reconstruction.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
2.1. Clinical characteristics
From January 1997 to December 2003, 158 patients underwent LV aneurysm repair at Novosibirsk Research Institute of Circulation Pathology. There were 152 men and 6 women, with a mean age—50±8.4, the mean stenocardia functional class—2.7±0.9, the mean NYHA functional class—2.9±0.6, and the average number of myocardial infarctions amounted to 1.5±0.7.

2.2. Echocardiography
All patients underwent M-mode and two-dimensional echocardiography both preoperatively and postoperatively.

To estimate the shape of LV, we measured the length (L) of LV during diastole from the apical position, and the end-diastolic diameter (D) was measured from the parasternal position. The index of sphericity (IS) of LV was determined using the following formula:


{4009479.475.si4}

The index of sphericity varies from 1 (ellipse) to 0 (sphere) [15].

To estimate the contracting function of LV, LV volumes, the global ejection fraction (EF) and the contractile ejection fraction were determined [16,17].

Depending on contractility of the nonaneurysmal portion of the LV, all aneurysms were divided into two types. Type I of the LV aneurysm was determined in 125 patients (79%) and included the aneurysms with good contraction of the nonaneurysmal portion of LV due to hyperfunction of the basal parts of the IVS, lateral and posterior wall of the LV, and, respectively, contractile EF was more than 0.5. Type II of the LV aneurysm was determined in 33 patients (21%) and included the aneurysms with poor contraction of the nonaneurysmal portion of LV and with segments of hypokinesia or akinesia, and extensive injury of the IVS or involving the segments of posterior wall of the LV and, respectively, contractile EF was less than 0.5.

On estimation of the mitral valve dysfunction the one or another grade of the mitral regurgitation was determined in 130 patients (82%). Although, the grade 1 of the mitral regurgitation was in 58% of the cases and only six patients (4%) had the mitral insufficiency of the grade 3–4, which was the indication for the surgical correction. It is necessary to underline that the posterior localization of LV aneurysm was the reason of the severe mitral regurgitation in the most cases (four patients).

Using the technique introduced by us before, we performed preoperative modeling of the optimal end-diastolic volume (EDV) of a ‘new’ LV required to support a normal cardiac output after aneurysm repair [18]. By taking into account the proper stroke index (SI) equal on average to 40ml/m2, the body surface area (BSA) and the contractile ejection fraction of LV (EFcLV), we determined the optimal EDV of LV (OEDV LV) by the following formula:


{4009479.475.si5}

To determine LV surface area, we outlined the border of EDV of LV on the echocardiograph screen and obtained a section of LV divided into 20 disks. A simple computer program developed at our hospital allows us to calculate a value of LV surface area by processing the magnitudes of 20 radii, LV longitudinal axis and scope. Thus, we can calculate the surface area of an initial LV with aneurysm and the surface area of a projected ‘new’ LV [18]. The permissible area of aneurysm repair was calculated using the difference between the initial and projected surface areas of LV.

2.3. Surgical technique
All operations were performed with cardiopulmonary bypass and aortic cross clamping. Moderate systemic hypothermia (28–30°C) and crystalloid or blood cold antegrade cardioplegia were used. We used IABP on the patients with severe LV dysfunction (12% of cases), which was installed 1 day before the operation.

The most of the patients (96%) had the anterior localization of the LV aneurysm and six patients (4%) had the posterior localization. The anteroseptal LV aneurysm was observed in 117 patients (74%), anteroapical—in 32 patients (20%), anterolateral—in three patients (2%) and posterobasal—in six patients (4%).

Ventricular reconstruction was performed using conventional linear plasty of LV (Cooley technique) in 35 patients, septal plasty of LV and IVS (modified Stoney technique) in 57 patients, and endoventriculoplasty with a synthetic patch (Dor-Cooley-Matas technique) in 66 patients.

As for the associated procedures, thrombectomy was performed in 101 patients (64%), myocardial revascularization—in 145 patients (92%), mitral valve anuloplasty—in five patients, tricuspid valve anuloplasty—in one patient and mitral valve replacement—in one patient.

Preoperatively, the permissible area of aneurysm repair is calculated whilst carrying out preoperative ‘new’ LV modeling. Intraoperatively, the surgeon measures the scar area of LV aneurysm using a ruler, and compares it with the permissible area of aneurysm repair.

When the scar area of LV was equal to the permissible area of aneurysm repair calculated preoperatively, we used linear or septal plasty of LV without disrupting LV geometry.

In other cases, when the scar area of LV was larger than the permissible area of aneurysm repair, we used endoventriculoplasty with a patch in order to avoid inadequate reduction and deformation of LV cavity.

2.3.1. Linear LV plasty
One of the requirements for linear plasty of LV is an intact IVS. Simple excision and linear closure were used to repair anteroapical or anterolateral aneurysms of LV.

When performing linear plasty of LV, the scar area of the aneurysm measured intraoperatively with the help of a ruler was 29±6cm2 and matched the permissible area of aneurysm repair of 32±5cm2 measured preoperatively (Table 1).


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  		Table 1. Preoperative and operative parameters of LV aneurysms
 
2.3.2. Septal plasty of LV and IVS
Septal plasty of LV and IVS with the modified Stoney's technique was used for the reconstruction of anteroseptal aneurysms of LV.

The longitudinal incision was made over the apex and the thinnest portion of the aneurysm. The free lateral margin of the LV was sutured to the IVS on the transition zone between scarred and normal endocardium with 3-0 continuous polypropylene sutures from base to the apex. After this we sutured the free medial margin of the LV with the second number of continuous sutures over the previous, so that anteroseptal aneurysm was excluded.

When doing septal plasty, the scar area of aneurysm was 45±6cm2 and correlated with the permissible area of aneurysm repair calculated preoperatively and equal to 42±6cm2 (Table 1).

2.3.3. Endoventriculoplasty
Endoventriculoplasty with the synthetic patch was applied for anteroseptal or posterobasal aneurysms of LV.

To repair anteroseptal aneurysms, an incision was made into the ventricle, 2–3cm lateral and parallel to the left anterior descending coronary artery. We applied the purse-string suture to the border of the scar and normal endocardium and formed a new neck of the LV. After that, the synthetic ‘Vascutek’ patch was sutured with continuous suture in position of the new apex of the LV. In some cases of the patients with the type II of the LV aneurism, where were an extensive injury of the IVS, it was impossible to suture the patch to the junction between the scar and normal endocardium that could decrease the LV cavity. In these cases the patch was inserted in to the estimated position as the measurement the length from the mitral valve to the line of attachment of the patch on the septum, lateral and posterior wall of the LV. We did not use a purse-string suture in some cases and used the different distention between the suture on the patch and wall of the LV for reduction the neck of the LV aneurism. Next, we filled up the LV and if it was necessary we fixed the patch by additional sutures for better hermetization of the LV. The aneurysmal wall was partly excided and sutured over the patch by means of over-and-over suturing.

When performing endoventriculoplasty, the scar area of the aneurysm measured intraoperatively amounted to 64±17cm2 and was greater than the permissible area of aneurysm repair calculated preoperatively and equal to 49±14cm2.

In these cases linear plasty of LV or septal plasty of LV and IVS could not be used, as removal of the whole scar area of LV aneurysm would lead to a considerable reduction of LV cavity. The difference between the required and permissible areas of aneurysm repair was compensated for by a synthetic patch, the area of which averaged to 16±3cm2 (Table 1).

Septal plasty with the remainder of the scar tissue is impossible in these cases, as it is required to completely exclude the endocardial surface of LV modified by thrombi.

We noted that the most severe dysfunction of LV contracting capacity was observed in patients who had undergone endoventriculoplasty. The contractile ejection fraction of LV averaged to 42±12% in the group with endoventriculoplasty, 49±5% in the group with septal plasty, and 53±4% in the group with linear plasty. Therefore, it is necessary to provide a greater optimal end-diastolic volume of the ‘new’ LV for patients with a low contractile ejection fraction (Table 1).

2.4. Statistical analysis
All values are expressed as the mean±SD. The comparisons between preoperative and postoperative data were statistically analyzed using paired or nonpaired Student's test. Significance was achieved at a P value of less than 0.05. The comparisons between groups were calculated by {chi}2 analysis.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
All surviving patients were examined early postoperatively before discharge from the hospital, and 112 patient (76%) had late postoperative examination over a period of 1–5 years, with mean follow-up time 23±11 months.

During the control study of the patients a significant improvement in their clinical state was revealed postoperatively, which manifested itself in a decrease in the mean NYHA functional class from 2.9±0.6 to 1.9±0.8 after operation. A significant reduction in the mean stenocardia functional class from 2.7±0.9 to 1.4±0.7 after the operation was also revealed.

A significant postoperative improvement of the LV contracting function regardless of LV plasty technique used was noted (Table 2).


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  		Table 2. Changes in LV contracting function depending on the technique of aneurysm repair
 
The changes of the LV geometry are resulted in improvement of the mitral valve function, the mean grade of the mitral regurgitation was decreased from 1.4±0.7 to 0.7±0.6 after operation.

A surgical reconstruction of postinfarction LV aneurysm result in changes dimension and shape of LV. However, the changes in geometry of LV varied from different techniques of LV plasty (Table 3). After septal plasty the EDD decreases significantly, but length of LV changes insignificantly, thus LV has more elliptical shape after operation (Fig. 1). The endoventriculoplasty significantly shortens the length of LV, but leaves the EDD unchanged and this lead to increase diastolic sphericity after operation (Fig. 2).


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  		Table 3. Changes in LV shape depending on the technique of aneurysm repair
 


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  		Fig. 1. Left ventricular shape before (a) and after autoventriculoplasty (b).

 


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  		Fig. 2. Left ventricular shape before (a) and after endoventriculoplasty (b).

 
During 30 days after operations, 10 patients died, with hospital mortality amounting to 6.3%. By carrying out the comparative analysis we did not find any significant difference in the hospital mortality versus the type of LV plasty used. Thus, with LV linear plasty the hospital mortality was 2,9, with septal plasty—7.0% and with endoventriculoplasty—7.5%. This difference was not statistically significant, however, the initial functional state of patients in different groups varied significantly. So, the severest injury of LV was observed in a group of patients who had undergone endoventriculoplasty (Table 1).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
Despite the anatomical and theoretical physiological advantages of the new reconstruction techniques, one problem remains unsolved: what is the most efficient technique for the correction of postinfarction LV aneurysms?

Kesler et al. compared the results of linear plasty and patch endoventriculoplasty and found no significant difference in mortality, angina, congestive heart failure, or echocardiographic variables [7].

In their studies Komeda et al. also did not find difference in mortality among various types of LV aneurysm repair, although they noted a tendency for the survival rate to improve after endoaneurysmorrhaphy in patients suffering from initial low EF [19].

Laboratory studies on animals carried out by Nicolosi et al. [20] did not reveal a difference in the systolic and diastolic functions of LV between LV linear plasty and plasty with a synthetic patch.

Elefteriades et al. published the findings of their multi-clinic study where they failed to detect a difference in hospital mortality rates and a significant difference in LV function values after various types of LV plasty [9]. On the basis of the EchoCG and MRI data, the authors came to the conclusion that all types of LV plasty are efficient enough if the cavity of LV is not deformed and the volume of LV is not left inadequate.

Tavakoli et al. did not find any significant difference in hospital mortality, functional state and survival rates of those patients who underwent endoventriculoplasty and LV linear plasty [21].

Whilst analyzing the worldwide experiences in the surgical treatment of postinfarction LV aneurysms, most surgeons are giving now their preferences to the more physiological procedures of LV reconstruction, such as endoventriculoplasty [11–15]. However, there are studies, which confirm good results for the septal technique of LV aneurysm repair obtained using Stoney's procedure [8,10,22]. This ‘forgotten’ technique is particularly effective for large anteroseptal LV aneurysms, which is proved by the postoperative improvement in LV function according to MRI data [22].

The study carried out by Hutching et al. [23] proved, on the basis of post-mortem examination data, that mortality after aneurysmectomy with linear plasty was due to a considerable reduction and deformation of LV cavity. Di Donato et al. [15] revealed that some changes of LV shape after the Dor procedure contribute to the enlargement of LV sphericity, because its longitudinal axis is shortened, with its diameter remaining unchanged. Salati et al. [24] observed severe diastolic dysfunction of LV after endoventriculoplasty when the LV length was inappropriately reduced and the patch was too small in high-risk patients.

Thus, with inadequate correction, we may have a long and narrow LV after linear plasty, or a short and spherical LV after endoventriculoplasty. In our study we found out that LV tends to have a greater elliptical shape after linear plasty and acquires a more spherical form after endoventriculoplasty (Table 3).

In spite of, endoventriculoplasty being considered a ‘more geometry’ technique of LV reconstruction, we believe that in cases when there is no danger of reducing and deforming the LV cavity, we can use LV autoplasty techniques without resorting to a synthetic akinetic patch.Indeed, we used endoventriculoplasty in cases when we had more severe damage of LV and implantation of patch was necessary in order to avoid inadequate decrease LV cavity after operation. This is why it is of great importance to estimate the permissible area of aneurysm repair.

Hence, various types of LV plasty are sufficiently effective during surgical treatment of cardiac aneurysms. According to various researchers the postoperative improvement of the patients' clinical state does not depend on a type of LV plasty used. The hospital mortality rate varies insignificantly when different types of LV plasty are used. However, in patients with prominent dysfunctions of LV, endoventriculoplasty works particularly well.

In conclusion, our results were shown the effectiveness of different techniques of LV aneurysm repair, when was applied the differential approach to choice an adequate method of ventricular reconstruction.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr C. Mestres (Barcelona, Spain): According to what you show, what was your actual definition of aneurysm? Did you include aneurysms only or akinesia as well, because some of the echoes that you showed were probably not strictly aneurysms?

Dr Marchenko (Novosibirsk, Russia): I am sorry, can you repeat your question?

Dr Mestres: What was the actual definition for you of LV aneurysm, because to me, some of the echoes that you showed were more akinesia instead of left aneurysm?

Dr Marchenko: We determined left ventricular aneurysm when we have segment dyskinetic or akinetic segments in the left ventricle during echocardiography or ventriculocardiography.

Dr Mestres: So then did you include akinetic segments instead of dyskinetic segments?

Dr Marchenko: Yes.


   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. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

  1. Cooley DA, Collins HA, Morris GC, Chapman DW. Ventricular aneurysm after myocardial infarction: surgical excision with use of temporary cardiopulmonary bypass. J Am Med Assoc 1958;167:557.
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  16. Wyatt HL, Meerbaum S, Heng MK, Gueret P, Corday P. Cross-sectional echocardiography III: analysis of mathematic models for quantifying volume of symmetric and asymmetric left ventricles. Am Heart J 1980;100:821-828.[CrossRef][Medline]
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  18. Cherniavsky AM, Karaskov AM, Marchenko AV, Mikova NV. Preoperative modeling of an optimal left ventricle volume for surgical treatment of ventricular aneurysms. Eur J Cardiothorac Surg 2001;20:777-782.[Abstract/Free Full Text]
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  20. Nicolosi AS, Weng ZC, Detwiler PW, Spotnitz HM. Simulated left ventricular aneurysm and aneurysm repair in swine. J Thorac Cardiovasc Surg 1990;100:745-755.[Abstract]
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