Left ventricular aneurysm

22 Pages·2004·1.8 MB·English

Leftventricular aneurysm: Twenty-year surgical
experience with 1572 patients attheTexas Heart Institute
Sitaram B. Reddy, M.D., Denton A. Cooley, M.D.,
J. Michael Duncan, M.D., andJohn C. Norman, M.D.
From January 1958 through December 1979, 1572 patients underwent
surgery for leftventricular aneurysm (LVA) in our institution. The series in-
cluded 1365menand207women,witharatioof6.5:1.Agesrangedfrom25
to 79 years, with a mean of54.7 years. Most patients were in NYHAfunc-
tionalClass IllorIV,andallhadsustainedatleastonedocumentedmyocar-
dial infarction. Duringthefirstdecade, LVAresectionalonewasperformed,
butaftertheadventofaortocoronary bypass (ACB)surgery, the majorityof
patients underwent ACB along with LVA resection. Some required addi-
tional septoplasty, mitral valve replacement, annuloplasty, or aortic valve
replacement. In all groups, the mortality was higher for women than for
men. Early deaths were due primarily to acute or progressive myocardial
failure secondaryto recurrent myocardial infarction. Follow-up information
for6monthsto8yearswasobtainedbymeansofquestionnairessubmitted
to patients and referring physicians. Of 475 patients who underwent LVA
resection and ACB and who responded, 92.2% were either improved or
asymptomatic.
Leftventricular aneurysm (LVA) isafrequentcomplicationofmyocar-
dial infarction and is occasionally the result of trauma, nonspecific
myocarditis, bacterial endocarditis, orcongenital malformations. Thein-
cidenceisreportedas 12% to 15%,butitcanbeashighas38% in patients
who have sustained a major myocardial infarction.1-3
From the Division ofSurgery, Texas Heart Institute ofSt. Luke's Episcopal and
TexasChildren's Hospitals, Houston,Texas.
Address for reprints: John C. Norman, M.D., Texas Heart Institute, P.O. Box
20269, Houston,Texas 77025.
CardiovascularDiseases, BulletinoftheTexasHeartInstitute
Volume8 Number2 June1981
165
Leftventricularaneurysnmscanbeeithertrueorfalse,andthetrueones
canbeeitheranatomical orfunctional (Fig. 1). 'I'he underlyingetiology is
arteriosclerotic stenosis or occlusion of' the coronary arteries, most f're-
quently oftheleftanteriordescending(LAD)coroncar-yartery. Theaneu-
rysms are usually located in the anteroapical region of the leftventricle.
Clinical manif'estations, inorderoffrequency, includecongestiveheart
failurewithorwithoutangina, thromboembolism, and ventricular tachy-
arrhythmias. The patient's clinical course can be improved by excision of
the scarred, noncontractile wall and restoration of a normal f'illing vol-
umeand normal geometricchamberconfiguration. Mostpatientsalsore-
quire concomitant aortocoronary bypass. Intracavitary nurlal thrombi
arereportedinupto50% ofpatientswithLVA; fortunately, suchthromnbi
manifestclinically inonly 5% ofcases.
The present report describes our experience with 1572 patients over
the last 20years.
Patients and Methods
Prior to 1969, we used resection alone to treat left ventricular aneu-
rysms. Since that time, LVA resection has been conmbined with aorto-
coronary bypass (ACB) whenever feasible and with valve replacenment
whenrequired. Duringthelast fewyears, we have performed septoplasty
along with aneurysmectomy in cases that involved extensive septal scar-
ring.
In this series of' 1572 patients, 100 uniderwvent LVA resection wvithout
ACB from 1958through 1969 (Group 1). Fromii 1969through 1979, 1251
patients underwent LVA resection combined with AC,B (Group 2). Dur-
ingthe same period, 221 patients had LVA resection alone, because asso-
ciated coronaryarterydiseasewasnotamenabletobypass ((Group3), and
421 patients underwent septoplasty along with aneuLrysmectomy and
ACB (Group4)(Table I). Asmnallnumberofpatients neededconcomitant
mitral valve replacemen-t, annuloplasty, oraor-tic valve replacemllent. 'The
series included 1365 imeni and 207 womien, with ac ratioof'6.5: 1. The ages
rangecl f'ronm 25 to 79 years, with a mean of 54.7 years. All patients had
sustained at leastonedocunmented mnyocardial inifIarction.
According to the NYHA functional classification, most of'the patients
were in Class III or IV; the most common manifestation was congestive
heart f'ailure, with orwithout angina.
Diagnosis was confirmed by means of'cardiac catheterization, left ven-
triculography, and selective coronary arteriography. During the last few
years, echocardiography and left ventricular performance studies with
isotope techniques have been perfornmed in addition to the above proce-
dures.
Group 1
Group 1 consisted of' 100 patients who underw-renit LVA resection with-
out AC,B bef'ore the advent ofaortocoronary bypass f'romn 1958 through
166
(A) systole True Anatomic diastole
(B)
(C)
Fig. 1 Heartin systoleanddiastole, showing (A) trueanatomic, (B) falseanatomic, and (C)
functional leftventricular aneurysms and healed myocardial infarction. Trueandfalseaneu-
rysmsprotrudeduringbothsystoleanddiastole,whereasfunctionalaneurysmsprotrudeonly
during systole. Trueaneurysms havewider mouthsandthickerwallsthanfalseaneurysms.
(Based on HS Cabin andWC Roberts: SpecialCommentary, Chest77(5): 587, bypermis-
sion.)
167
TABLE SummaryofLeftVentricularAneurysms (THI)
I.
(January 1958-December 1979)
Number
Procedure TimePeriod ofPatients
LVAresectiononly Jan 1958-Dec 1969 100
LVAresection plusACB* Dec 1969-Dec 1979 1251
LVAresectiononly Dec 1969-Dec 1979 221
TOTAL 1572
*Between Dec. 1974 and Dec. 1979, 421 patients underwent resection plus ACB
plusseptoplasty. LVA = leftventricularaneurysm; ACB = aortocoronarybypass
1969. The ratio of men to women was 7:1. Of these patients, 65%Y had
symptoms ofcongestive heart failure, 30% had congestive heart failure
with angina, and only 5% presented with angina as the major symptom.
Intractable ventricular tachyarrhythmias were prevalent in two patients.
Ofthe60patientswhounderwentcoronaryangiography, 77% hadmulti-
plevesseldisease,and23%hadcompleteocclusionofamajorvesseltothe
aneurysmal area. Theaverage leftventricular end-diastolic pressure was
greater than 20 mm Hg.
Group 2
From December 1969 through December 1979, LVA resection with
concomitant ACB was performed in 1251 patients, including 1099 men
and 152 women. In a large percentage ofthese patients, angina was the
major presentingsymptom, followed bycongestive heart failurewith an-
gina. Congestive heart failure alone was present in only a small percent-
age. Intractable ventricular tachyarrhythmias and clinically manifesting
thromboemboli wereat the bottom ofthelistofpresentingcomplaints.
Cardiac catheterization with left ventriculography and selective coro-
nary angiography was carried out in all patients. Depending on angio-
graphic and operative findings, one to four or more coronary arteries
were bypassed with reversed saphenous vein grafts. These included 288
single, 429 double, 409 triple, 108 quadruple, and 17 quintuple or more
grafts (Table II).
Inorderoffrequency, theaneurysms werelocated in theanteroapical,
apical, posteroinferior, and lateral portions ofthe left ventricle. In over
90% ofcases, theanteroapical portionwasaffected (Fig. 2).The LADwas
themostcommon vessel involved; ifthelesion was proximal to thediago-
nalorseptal branches, the LAD was bypassed whenever possible.
168
TABLEII. SummaryofAortocoronary Bypasses PlusLeftVentricular
Aneurysm Resection(THI)
(December1969-December1979)
TotalNumber Quintuple
ofPatients Single Double Triple Quadruple orMore
1251 288 429 409 108 17
Anteroapical
Pbsteroiferior
Lateral
Fig.2 Inorderoffrequency, aneurysmsarelocated intheanteroapical, apical, posteroinfe-
rior,andlateralportionsoftheleftventricle.
Afewoftheaneurysmsoftheposteriorordiaphragmaticsurfaceofthe
leftventricle had caused damage to the papillary muscles, with resultant
mitral regurgitation. Although the milder forms of regurgitation were
eliminated with the restoration ofnormal ventricular contourafter LVA
resection, some patients required either mitral annuloplasty or valve re-
placement.
169
Group3
In Group 3, 221 patients underwent LVA resection without concomni-
tantACJB from December 1969 through Decenmber 1979. Theseincluded
178 men and 43 wonmen. Associated coronar',,y artery- occlusive (lisease
(CAOD) waseitherhemodynamically insignif'icatntornotamieinabletoby-
pass. The site of' the aneurysm and the most commonly af'f'ected vessel
were the sanme as in the other groups. Congestixe heacrt f'ailLire wtas the
predominaint symptonm; smiall percentage of patients also had angina.
a
Ventriculcar tachyarrhythmias and peripheral thromboemnboli wvere pres-
ent in a small numnber.
Group 4
Group4 included 421 pattients (379 men and 42 women). Besicdes LVA
resection andi ACB, septoplasty was perf'ormed whenever extensivescar-
ringoftheseptum causecd pariacloxical miotion. 'lechniquesof'septoplasty
are described below. The number of'af'f'ected coronary arteries is shown
in Table III.
Surgical Technique
SUrgical Iepair- was perfOrme(l through a median sternotomv; if con1-
comitant ACB was needled, the greatter sapheous vein W*ls ulsecd. After-
the pericardulilm hadc been openedl, only suf'ficienit clissectioni was per-
form-ned to eXpOse the r-iglht atrium and ascending aorta f'or- cannulalltiol.
Adhesions over the aneur-vsmal area were left undisturbed uLintil cardio-
pulmoiary bypass hadcl been initiated and the ascending ao-ta hadbleen
TABLE Ill. LeftVentricularAneurysm ResectionwithAortocoronary
BypassandSeptoplasty(THI)
(December 1974-December 1979)
Vessels Involved NumberofPatients
Single 87
Double 138
Triple 152
Quadruple 39
Quintupleormore 5
TOTAL 421
(379 Malesand42 Females)
170
cross-clamped to prevent embolization of' nmural thrombi from the left
ventricle. Therightatrium wascaniulated forvenousoutflow with either
a single large-diaimietei catheter or wvith two vena caval catheters, and the
ascending aorta was cannuLlated f'io arterial returl-. Under special cir-
cumnstanices (f'orexaimlple, with patieints who wvere undei-goinig repeatsur-
geryorwhoseconditionlwIvasunstable), pairtialbypasswasachievedbycan-
nlUlatinga f'emoral vein ancl artery.
Since 1962, we have employed the hemodilutioin perf'usion technique
wviththeuseof'disposablebubbleoxvgenatorsprimedw'ith5% dextrosein
Ringer-'s lactate solution. For thelast fewvears, wvehave usedcardioplegia
for nwvocardial protection, injecting cold potassiunm (K+) solution* into
the aor-tic root af'tei-cross-claimiping the ascenidingaorta.
Duriing the early part of'our experience, we used normlothernia wvith
ischemic arrest; this technique was later replaced by general body hypo-
therm-lia(toapproximately 28-30(A) andlocalcardiaccoolingwithicedsa-
line solutioin; in recenit y'ears, the latter method has been supplanted by
the useof'car-dioplegia.
Af'ter the induction of'car-dioplegia, the left sicle of the heart was de-
coImlpressed with a sump placed through the right superior pulmonary
vein into the left atr-iumIa; (presently, decompression is achieved by means
of'an- aspirating needle inisei-ted inlto the anterioi- aspectof'the ascending
aoi-ta). At this stage, thie aneurysm was dissected f'ree from the pericar-
diumi. Forlargelesions withdenseadhesions, theaineurvsnmal w'Vallwasleft
attached to the pericardiumli and excision was performed through the
scar-r-ed miiai-ginof'theleft ventricle. Although the remainiilgdetailsofex-
cisionand repairhavebeen described elsewhere, abrief'mentionof'aneu-
rysms of'the posterior or diaphragmatic surface of'the left ventricle is in
order. These aneurysms wvere repaired in the samle manner- as the more
conmmon types; the only dif'ferenice wvas that, in a f'ewv patients, mitral re-
guri-gitation resultecd f'ronm clamagetothe papillary muscles. Although res-
tor-ationof'thenormal ventricularcontoureliminated the mailderf'ormsof'
regurgitation, a f'ew patients requii-ed either annuloplasty or mitral valve
replacemlenit.
Aortocoronary bypass was perf'ormed with the use of' the greater
saphenous vein; in the majority of' cases, the LAD that supplied the
aneurysmal area was bypassed if'the lesioniwas proximal to the cliagonal
orseptal branches.
Since 1974, we have perf'Oriled septoplasty whenever necessary, in ad-
ditionto LNA r-esectioinand ACB. Theaneurysm cauLsed bythromibosisof'
the LAD ailInlost alwavs produced da(la-ige to the ad-jcent septuml. The
*(Contenlts per500cc of -5,7 dextrose and 0.4%k MNCI: PotassiLumiichloride, 20 imNM
(1492.()mg); maginesiuLm1 chlor-ide, 7.5iimNM (1527.0tmlg);SOCdiuLmIlbicarbonate, 2.5
mMSN (21(0 mig); calciulIl chloride, i.t) mMSN (147 mg).
171
scarred portion ofthe septum wvasoften extensiveelnouLgh thatitcontrib-
utedsignif'icantly totheparadoxicatl contr-actioni pattern ofthelef'tventri-
cle. Hence, aspecial ef'f'oi-twas madetocorrect theseptal paradoxical m)o-
tion.
Figure 3 illustrates the pref'erred method ofseptoplasty. A knitted Da-
cron velour patch is tailored to a size considerably smiaillei thalni the
scarredarea. After the patch hasbeensutuLredl intoplace, theseptal aneu-
rysm is di-awn into a smaller overall area. Final repair of' the aneur-vysmi
andclosure ofthe ventriculotomy iscompleted in the USLal nmanner. The
E. 1,/
rr" frObAA-e
Fig.3 Techniqueofventricularseptoplastyusingfabricpatchgraft.(FromDACooleyandWE
WalkerinSurgeryfortheComplicationsofMyocardialInfarction, editedbyJMMoranandLL
Michaelis,publishedbyGrune&Stratton, Inc., 1980,p.279,bypermission.)
172
cross-sectional diagranm reveals how the patch graftreshapes the left Xven-
tricle, reinforces theseptum, helps preventembolizationfrom theragged
thrombosed surface, and improves ventricular function (Fig. 3 [inset]). A
second method of septoplasty, illustrated in Figure 4, entails the place-
mentof'interrupted mattresssuturestoclosetheventriculotomy through
the posterior partoftheseptum, thusobliteratingtheakineticseptal por-
tionoftheleftventricle. Onefeltstripliestotherightoftheinterventricu-
lar groove, possibly causing occlusion of'the perf'orating branches of'the
LAD. Despite this theoretical objection, reported results have been satis-
D.
eL
III
Edges
Free wall of LV. oversewn
sewn to septum
RV L
r1/ /.>
Fig.4 Techniqueofexcisionforposterior (diaphragmatic) ventricularaneurysms. (From DA
CooleyandWEWalkerin Surgeryforthe ComplicationsofMyocardialInfarction, edited by
JMMoranandLLMichaelis,publishedbyGrune&Stratton,Inc.,1980,p.280,bypermission.)
173
fIactory. We believe, however, that the LAD should Inot be encir-cled with
sutures, becausethey may disturbthe residual myocardialcircUlation and
preventarterial recanalizatioil.
Postoperative intriaaortic balloon puimlping has beell usedl in appr-oxi-
mately 7% of patients who had difficulty comIing oofffbypass or who had
imimediate postoperative leftventricular f;ailure. 'heaveragedluration of'
IABP 36 hours.
was
Results
In all groups, early deaths were due primarily to atcute or progressive
myocardial f:ailure orwere secondary to recuLr--ent mvnvocardial iiL-f'trctioll.
Othersignif'icantpostoperativecomplicationls inCIludclecd arrvhvthmi-ias,coIn-
gestive heart f;ailure, aind postcardiotomy synldrome.
Group 1
The 100 patietnts who unider-weint lXA resectioni fr-oIm 1958 tlllhoughl
1969 had an early mortality (less than 30 days) of 19%S/ (19 patieIts). NMost
ofthosewhodied had exhibited preoperativecliiicaloraingiogr-aphicevi-
dence of'severe coronary artery occlusive disease.
Of' the survivors, 25% developed electrocardiographic evidence of'
myocardial inf;arction duriing the early postoperative period. Smmptoms
TABLEIV. Mortalitywith LeftVentricularAneurysm Resectionand
Aortocoronary Bypass(THI)
(December 1969-December1979)
Early Late
Grafts Patients Deaths Percent Deaths Percent
Single 288 25 8.68 35 12.15
Double 429 40 9.32 40 9.32
Triple 409 27 6.60 27 6.60
Quadruple 108 11 10.19 4 3.70
Quintuple
ormore 17
TOTAL 1251 103 8.23 106 8.47
Males 1099 85 7.73 90 8.19
Females 152 18 11.84 16 10.53
174