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Ann Thorac Surg 1996;61:271-272
© 1996 The Society of Thoracic Surgeons

Updates

The Use of Autologous Pericardium for Ventricular Aneurysm Closure

As Originally Published in 1988:

Updated in 1996 by Andrew C. Fiore, MD, Gregory A. Misbach, MD, Peter P. McKeown, FRCS(C), Margaret D. Allen, MD, Marc T. Swartz, BA, and Tom D. Ivey, MD

Division of Cardiothoracic Surgery, St. Louis University Health Science Center, St. Louis, Missouri, and the University of Cincinnati Medical Center, Cincinnati, Ohio

The traditional technique for surgical repair of left ventricular aneurysm was first reported by Cooley and associates [1] in 1958. It consisted of aneurysmal sac resection followed by linear closure of the ventriculotomy with suture line reinforcement using Teflon strips. Our publication [2] modified this closure by employing autologous pericardium for suture line reinforcement of the aneurysm wall. Since this publication, 11 additional patients at our institution have had successful LV aneurysm repair using autologous pericardium for linear closure.

There has been considerable change in recent years regarding surgical repair of LV aneurysms. First, the frequency of aneurysm operations has declined precipitously. A review of our experience at St. Louis University Health Sciences Center reveals a sharp decline over the past 20 years (Fig 1Go). Currently only 0.5% of patients who require myocardial revascularization undergo concomitant aneurysm repair. It is our theory that fewer patients require aneurysm operations because large anterior wall transmural myocardial infarctions are now often interrupted using thrombolytic therapy in conjunction with balloon angioplasty or emergency surgical revascularization, thus preventing aneurysm formation. Although the infarction may not be completely prevented, the affected area frequently heals with retained viable myocardium, which does not have the potential for later dilatation.



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  		Fig 1. . Percent of patients who required left ventricular aneurysm repair at the St. Louis University Group Hospitals.

 
Alterations have also occurred in operative technique, with the most prominent change being the introduction of endoventricular patch plasty originally introduced by Jatene [3] in 1985 and later modified by Dor and associates [4] as well as by Cooley [5]. The goal of this technique is to replace the aneurysmal myocardial wall with an elliptical patch graft of biological or synthetic material. This is done to restore the geometry, contour, and volume of the left ventricle in diastole while simultaneously reducing end-systolic volume. Patch reconstruction allows circular reorganization of the remaining left ventricular muscle, which cannot be accomplished using traditional linear closure [6]. In addition, circular reconstruction of the left ventricle permits revascularization of the left anterior descending coronary artery, which, in some authors' opinion [7, 8], improves operative outcome and long-term survival. Although controversy surrounds the optimal technique for left ventricular aneurysm repair, the newer circular patch reconstruction is associated with a lower operative mortality, improved early and late left ventricular systolic function, and enhanced survival [9–14].

Autologous pericardium still has several applications in the current surgical treatment of left ventricular aneurysm. If one wishes to use Dacron as the primary circular patch material, the pericardium may be sewn onto the Dacron patch as a ``lining'' so that the smooth visceral pericardial surface becomes the pseudoendocardium, potentially reducing the risk of clot formation on the patch. Some authors have even recommended that autologous pericardium be the primary material to restore circular geometry following left ventricular aneurysm reconstruction [15]. Finally, autologous pericardium can still be used as pledgets or as linear strips to reinforce any of the suture lines during circular reconstruction of the left ventricle. Unlike Teflon, autologous pericardium is compliant, readily available, inexpensive, and hemostatic. It also has the potential advantage of resistance to infection. For these reasons we continue to recommend its use in patients who require surgical treatment of left ventricular aneurysm.

Footnotes

Address reprint requests to Dr Fiore, Cardiothoracic Division, Department of Surgery, St. Louis University Health Sciences Center, 3635 Vista Ave at Grand Blvd, PO Box 15250, St. Louis, MO 63110-0250.

References

  1. Cooley DA, Collins HA, Morris GC, et al. Ventricular aneurysm after myocardial infarction: surgical excision with use of temporary cardiopulmonary bypass. JAMA 1958;167:557–660.
  2. Fiore AC, McKeown PP, Misbach GA, Allen MD, Ivey TD. The use of autologous pericardium for ventricular aneurysm closure. Ann Thorac Surg 1988;45:570–1.[Abstract]
  3. Jatene AD. Left ventricular aneurysmectomy resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321–31.[Medline]
  4. Dor V, Saab M, Coste P, et al. Left ventricular aneurysm: a new approach. Thorac Cardiovasc Surg 1989;37:11–9.[Medline]
  5. Cooley DA. Ventricular endoaneurysmorrhaphy: results of an improved method of repair. Tex Heart Inst J 1989;16:72–5.[Medline]
  6. Savage EG, Downing SW, Ratcliffe MB, et al. Repair of left ventricular aneurysm. J Thorac Cardiovasc Surg 1992;104:752–62.[Abstract]
  7. Jindani A, Williams BT. Survival after left ventricular aneurysmectomy with or without coronary artery bypass graft. Coron Artery Dis 1992;3:739–44.
  8. Mills NL, Everson CHT, Hockmuth DR. Technical advances in the treatment of left ventricular aneurysm. Ann Thorac Surg 1993;55:792–800.[Abstract]
  9. Di Donato M, Barletta G, Maioli M, et al. Early hemodynamic results of left ventricular reconstructive surgery for anterior wall left ventricular aneurysm. Am J Cardiol 1992;69:886–90.[Medline]
  10. Komeda M, David TE, Malik A. Operative risks and long-term results of operation for left ventricular aneurysm. Ann Thorac Surg 1992;53:22–9.[Abstract]
  11. Kesler KA, Fiore AC, Naunheim KA, et al. Anterior wall left ventricular aneurysm repair. J Thorac Cardiovasc Surg 1992;103:841–8.[Abstract]
  12. Salati M, DiBiasi P, Paje A, et al. Functional results of left ventricular reconstruction. Ann Thorac Surg 1993;56:316–22.[Abstract]
  13. Kawata K, Kitamura S, Kawata T, et al. Hemodynamic assessment during exercise after left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1994;107:178–83.[Abstract/Free Full Text]
  14. Kawata T, Kitamura S, Kawachi K, et al. Systolic and diastolic function after patch reconstruction of left ventricular aneurysms. Ann Thorac Surg 1995;59:403–7.[Abstract/Free Full Text]
  15. Juidashian JP, Follette DM, Contino JP, et al. Pericardial patch repair of left ventricular aneurysm. Ann Thorac Surg 1993;55:1022–4.[Abstract]



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 Ann. Thorac. Surg.Home page
R. Scrofani, M. Salati, P. Di Biasi, and C. Santoli
The Role of Autologous Pericardium in Cardiac Surgery
Ann. Thorac. Surg., January 1, 1997; 63(1): 291 - 291.
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