Eur J Cardiothorac Surg 2005;28:772-774
© 2005 Elsevier Science NL
Restoring an elliptical chamber during rebuilding a wrap around anterior infarction
Gerald Buckberg
a
,
*
,
Lorenzo Menicanti
b
,
1
,
Sergio De Oliveira
c
,
2
,
Constantine Athanasuleas
d
,
3
,
the RESTORE Team
a David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 62-258 CHS, Los Angeles, CA 90095-1741, USA
b San Donato Hospital, Via Morandi 30, Milan, Italy
c University of Sao Paulo Medical School, Sao Paulo, Brazil
d Norwood Clinic, 1528 Carraway Blvd., Birmingham, AL, USA
Received 27 June 2005;
received in revised form 12 August 2005;
accepted 16 August 2005.
* Corresponding author. Tel.: +1 310 206 1027; fax: +1 310 825 5895. (Email: gbuckberg{at}mednet.ucla.edu; menicanti{at}libero.it; sergioaoliveira{at}incor.usp.br; dra{at}norwoodclinic.com).
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Abstract
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Left ventricular geometry is distorted after anterior infarction caused by occlusion of a wrap around left anterior descending artery. Loss of the apex creates a spherical left ventricular (LV) chamber, whose rebuilding requires reconstruction techniques that exclude the non-functional inferior wall. The described technique of tailoring the apex defines a way to create an oblique elliptical rim for subsequent patch placement to complete the restoration procedure. This method of ventricular rebuilding differs from methods that follow the inferior wall scar, which result in a restoration procedure that leaves a spherical or box-like apical region.
Key Words: Wrap around anterior infarction • Conical chamber • SVR • Ventricular restoration
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1. Text
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The geometric goal in restoration after anterior infarction is to rebuild a conical left ventricular chamber, but this process differs following infarction caused by a wrap around left anterior artery, since this lesion damages the apical part of the inferior wall, and causes loss of the ventricular tip. The reconstruction method was initially described by Dor [1] as endoventricular circular patch plasty (EVCPP). With wrap around anterior infarction, rebuilding by following only the scar may reconstruct a spherical chamber shape, causing a box-like apex on postoperative analysis.
This report describes a restoration method that rebuilds the left ventricular apical tip by excluding the damaged inferior wall, thereby creating a focal point for using either the patch [2] or direct closure [3]. This tip position occurs after placement of the oblique Fontan suture [4] to create the surgical neck. This technique supplements the preciously described basic work of Dor [5] and thus avoids a potential structural dilemma that may arise if only the scar on the inferior wall is used during reconstruction. Otherwise the patch would occupy a more posterior position, lose angulation, may confront the mitral valve, distort conical geometry, and produce a spherical or box-like apex [6]
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2. Methods
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This report will describe a method used to restore more normal conical chamber dimensions by members of the RESTORE team in 25 patients with wrap around anterior infarction.
The right anterior oblique ventriculogram always shows an apical akinetic region, with extension of the non-contractile ventricular surface around the ventricular tip to include approximately the apical third of the inferior wall. All patients underwent patch placement to rebuild ventricular volume, with intraoperative creation of a new apex to exclude the scarred inferior wall. The creation of an oval neck with an oblique angle by the Fontan suture insured reconstruction of a conical chamber with a patch or direct closure.
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3. Results
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Fig. 1
(a) shows the anatomy of a wrap around left anterior descending coronary artery (LAD) infarction by right anterior oblique ventriculogram. Fig. 1(b) displays the open chamber; the incision is made about 2–3 cm from the LAD vessel, and is not extended beyond the apex. The extent of non-contractile muscle is determined by palpation in the beating heart. Apical inferior exclusion with cardioplegia is determined either by vision of muscle scar and thickness, or by prior right anterior ventriculogram.
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Fig. 1. (a) Left ventricular globular shape after wrap around anterior infarction with asynergic (non functional area) involving the apical part of inferior wall between bases of papillary muscles. (b) Intraventricular view of inferior scar via the ventriculotomy. shows how palpation can define of the non contracting inferior wall, and the method of excluding the scarred inferior wall by placing mattress sutures form exists from either (c) outside the ventricle to within the chamber, or (d) inside the chamber.
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Exclusion of the non-contractile inferior apical region by interrupted mattress sutures, from either within or without the LV cavity allows (a) narrowing of the widened apical inferior wall and (b) creation of an apex for patch placement. Interrupted mattress sutures are inserted into scarred muscle adjacent to the contracting inferior wall, either from within the chamber (Fig. 1(c)), or from the outside to within the cavity, and then from the cavity toward an external position on the inferior wall, as shown in Fig. 1(d). An alternate method is insertion of continuous sutures after making a tip of the base and apex, as described previously [7].
An apex is created by the tip of the inferior wall closure; Fig. 2
(a) shows how contractile muscle now surrounds the inferior wall imbrication site. This distal apical point is used when the Fontan suture creates an oblique oval neck that will become a rim for subsequent patch placement.
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Fig. 2. (a) Technique of patch placement in a chamber made more conical by (1) securing the inferior wall sutures, (2) placement of the oblique Fontan suture to create an oval rim for patch placement, and (3) placing sutures from around the Fontan oval into either suture holders or the patch. (b) shows the completed patch that is inserted in an oblique direction, using the apex of the inferior wall closure as the distal tip of the patch, and the upper septum as the upper tip, and the suture placed around the patch rim to help hemostasis.
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A series of sutures (Fig. 2(a)) are then placed around the Fontan suture guideline to create a ring for pericardial patch placement. The restoration technique is similar if hemashield, rather than pericardial patch, is employed. Alternatively, direct closure can be done without a patch. The geometric final objective of developing a conical chamber includes using the aforementioned inferior wall method, but is not dependent upon the selected ventricular closure method.
Fig. 2(b) shows the final patch position and its oblique angulation, while the excluded septum exists anterior to the patch.
A running suture is placed in the flange of pericardium above the patch ring. This added suture technique helps prevent potential bleeding that might happen if the patch is inserted upon the trabecular scar that sometimes exists after prior reperfusion by thrombolysis or angioplasty. The technique was used in 25 patients without complications. Ejection fraction increased from 27 ± 12 to 41 ± 7%, ESVI fell from 96 ± 30 to 49 ± 15 ml/m2, mean pulmonary artery pressure fell form 25 ± 9 to 16 ± 4 mmHg, and baseline cardiac output did not change.
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4. Discussion
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This procedure for restoration of the dilated heart following a wrap around LAD infarction defines how three-dimensional knowledge of the ventricular chamber dimensions improves ventricular rebuilding of size and shape toward normal by excluding the scarred inferior wall scar, and developing strategies to construct an oblique patch orientation to restore a conical shape [8]. While this shape rebuilding reconstructs the ellipse configuration of normal hearts, late comparisons to prior restoration procedures with more spherical chambers are needed to determine if this "how to do it" method has long term merit.
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Footnotes
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1 Tel : +39 02 5277 4514; fax: +39 02 5277 4327. 
2 Tel : +55 11 3825 1678; fax: +55 11 3825 6596.
3 Tel.: +1 205 250 6038; fax: +1 205 250 6867.
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References
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- Dor V. The treatment of refractory ischemic ventricular tachycardia by endoventricular patch plasty reconstruction of the left ventricle. Semin Thorac Cardiovasc Surg 1997;9(2):146-155.[Medline]
- Dor V, Sabatier M, Di Donato M, Montiglio F, Toso A, Maioli M. Efficacy of endoventricular patch plasty repair in large post-infarction akinetic scar and severe LV dysfunction. Comparison with a series of large dyskinetic scar. J Thorac Cardiovasc Surg 1998;116(1):50-59.[Abstract/Free Full Text]
- Menicanti L, Di Donato M. Surgical ventricular reconstruction and mitral regurgitation: what have we learned from 10 years of experience?. Semin Thorac Cardiovasc Surg 2001;13(4):496-503.[Medline]
- Fontan F. Transplantation of knowledge. J Thorac Cardiovasc Surg 1990;99:387-395.[Medline]
- Dor V. The treatment of refractory ischemic ventricular tachycardia by endoventricular patch plasty reconstruction of the left ventricle. Sem Thorac Cardiovasc Surg 1997;9(2):146-155.[Medline]
- Menicanti L, Di Donato M, Frigiola A, Buckberg G, Santambrogio C, Ranucci M. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002;123(6):1041-1050.[Abstract/Free Full Text]
- Athanasuleas CL, Buckberg GD, Menicanti L, Gharib M. Optimizing ventricular shape in anterior restoration. Semin Thorac Cardiovasc Surg 2001;13(4):459-467.[Medline]
- Athanasuleas CL, Buckberg GD, Menicanti L, Gharib M. Optimizing ventricular shape in anterior restoration. Semin Thorac Cardiovasc Surg 2001;13(4):459-467.[Medline]
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