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Ann Thorac Surg 1997;63:701-705
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Repair of Left Ventricular Aneurysm: Long-Term Results of Linear Repair Versus Endoaneurysmorrhaphy

Departments of Cardiothoracic Surgery and Cardiology, Boston University Medical Center, Boston, Massachusetts

Accepted for publication October 9, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Recently, endoaneurysmorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques.

Methods. Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair.

Results. The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 ± 0.08 versus 0.30 ± 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 ± 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 ± 0.64 versus 0.18 ± 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair (p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 ± 0.11 versus 0.27 ± 0.11; p = 0.90), left ventricular volume (171.6 ± 59.1 versus 169.9 ± 54.4 mL; p = 0.94), and sphericity index (0.61 ± 0.09 versus 0.61 ± 0.12; p = 1.0).

Conclusions. Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The first successful repair of left ventricular aneurysm was performed by Likoff and Bailey [1] in 1955. Linear repair of left ventricular aneurysm using cardiopulmonary bypass was reported by Cooley and associates [2] in 1958. The operative technique remained unchanged until the mid-1980s, when it became apparent that the clinical results were suboptimal. Early mortality was relatively high, in the range of 10% to 20%, and late results were also unsatisfactory, with many patients having persistent symptoms of congestive heart failure [3]. Attention was then focused on finding new methods of reconstruction to restore left ventricular geometry. These concepts were introduced by Jatene [3] and later modified by Dor and colleagues [4]. In 1989, more than 3 decades after his original report, Cooley abandoned linear repair for a new technique, which he termed intracavitary repair or endoaneurysmorrhaphy [5]. This simplified technique retains the aneurysm wall to allow closure over the intracavitary prosthetic patch with remodeling of the left ventricle, providing both excellent hemostasis and support and isolating the patch from the pericardial surface. Early reports documented a more favorable outcome after endoaneurysmorrhaphy, with improved postoperative hemodynamic indices and decreased early mortality [5–14]. However, there are few data available comparing the two techniques, particularly in terms of long-term results. The aim of this study was to compare the clinical results of endoaneurysmorrhaphy and linear repair up to 5 years after operation, correlating clinical outcome with echocardiographic measurements of left ventricular performance and geometry.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
Between July 1987 and January 1995, 47 consecutive patients underwent repair of left ventricular aneurysm. Between July 1987 and January 1991, linear repair wasperformed in 20 patients. In January 1991, we switched our operative technique to endoaneurysmorrhaphy, and since then it was performed in 27 patients. This study compares the early and late results of these two operative techniques. There were 33 men and 14 women, with a mean age of 63.7 ± 9 years and a mean New York Heart Association class of 3.6 ± 0.5. Forty-one aneurysms were anterior and six posterior, with no significant difference between the groups (endoaneurysmorrhaphy: anterior 22, posterior 5; linear repair: anterior 19, posterior 1; p = 0.15). Indications for operation are described in Table 1.

Hospital Data
Patient medical records were reviewed retrospectively. Data collected included the following: (1) demographic information—sex, age, indication for operation, date of operation, status of the procedure (elective versus urgent or emergent), primary procedure versus reoperation, and surgeon; (2) preoperative functional status and angina severity determined by the New York Heart Association classification; (3) comorbid risk factors—hypertension, diabetes mellitus, prior cerebrovascular disease, peripheral vascular disease, smoking, chronic obstructive pulmonary disease, chronic renal failure (creatinine level >3.5 mg/dL), dialysis, and prior myocardial infarction; (4) operative data—type of repair, concomitant procedures, cardiopulmonary bypass and aortic cross-clamp times, use of inotropic agents and intraaortic balloon pump, and intraoperative complications; and (5) postoperative complications—death, substantial morbidity defined as reoperation for bleeding, mediastinal infection, pneumonia, respirator use for more than 3 days, transient ischemic attack or cerebrovascular event, myocardial infarction (new Q wave, elevation of creatine kinase MB fraction 150 U), or low cardiac output state (a newly placed intraaortic balloon pump or the use of inotropic agents for more than 24 hours to maintain a cardiac index greater than 2.0), and other major complications (eg, vascular, gastrointestinal).

Long-Term Follow-up
All clinical records were reviewed. Direct telephone contact with the patient or family and the primary care physician was made in 44 patients (94%): endoaneurysmorrhaphy, 25 patients (92.6%); linear repair, 19 patients (95%). Data obtained included survival, functional status, long-term medical management, and procedure-related complications.

Echocardiographic Measurements
Early postoperative two-dimensional echocardiograms were performed in each patient before discharge (at postoperative day 5.5 ± 1.3 in the endoaneurysmorrhaphy group and at 5.8 ± 1.2 days in the linear repair group; p = 0.92), using Hewlett-Packard (Andover, MA) equipment. At this phase, no patient received inotropic support, and indices such as hematocrit and loading conditions were similar between the groups. Left ventricular ejection fraction was calculated using Simpson's formula from biplane apical four- and two-chamber views. Percentage increase in left ventricular ejection fraction was calculated as: Postoperative ejection fraction - preoperative ejection fraction/preoperative ejection fraction. To assess the geometric adaptation to the operation, we performed long-term echocardiograms in 27 patients (endoaneurysmorrhaphy 17, linear repair 10). Measurements included mid-left ventricular diameter, long-axis diameter, apical/mid-left ventricular diameter ratio, left ventricular volume, and sphericity index, defined as mid-left ventricular diameter/long-axis ratio (Fig 1). The more spherical the left ventricle, the closer to 1 are the apical/mid-left ventricular ratio and the sphericity index.

View larger version (21K): [in this window] [in a new window]   Fig 1. . Long-term left ventricular ( LV) echocardiographic measurements.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Early Results
There was no significant difference between the groups with respect to age, gender, urgency of the procedure, preoperative left ventricular ejection fraction, functional status, and comorbid risks (see Table 1). Indications for operation included angina, congestive heart failure, ventricular arrhythmias, or a combination of these presentations, with similar distributions between the groups (see Table 1). Operative data are summarized in Table 2. The duration of cardiopulmonary bypass and aortic cross-clamp time were similar. Concomitant myocardial revascularization was performed in 18 patients (90%) with linear repair and 21 patients (78%) with endoaneurysmorrhaphy (p = 0.18). The average number of grafts per patient in the linear repair group was 2.5 ± 1.1, and in the endoaneurysmorrhaphy group it was 2.2 ± 1.0 (p = 0.39). Specifically, the left anterior descending coronary artery was grafted in 13 patients (65%) in the linear repair group and 19 patients (70%) in the endoaneurysmorrhaphy group (p = 0.23). Thirty-day operative mortality after linear repair (Table 3) was 10% and after endoaneurysmorrhaphy it was 3.7%, but the difference was too small to reach significance (p = 0.32). All 3 patients who died early (one in the endoaneurysmorrhaphy group and two in the linear repair group) did so as a result of postoperative low cardiac output. They all had severe left ventricular dysfunction despite maximal inotropic support, intraaortic balloon pump, and in 1 case insertion of a left ventricular assist device. Intraoperative transesophageal echocardiograms obtained in these patients showed severe left ventricular dysfunction with adequate left ventricular volumes. The overall perioperative complication rate, use of inotropic agents, and use of intraaortic balloon pumps were similar (see Table 3). The preoperative mean left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group: 0.25 ± 0.08 versus 0.30 ± 0.09 (p = 0.032) (see Table 1). Postoperatively, the mean left ventricular ejection fractions were similar: endoaneurysmorrhaphy 0.34 ± 0.1 versus 0.31 ± 0.07 (p = 0.42). Thus, a greater increase in the early postoperative left ventricular ejection fraction was observed after endoaneurysmorrhaphy: 0.51 ± 0.64 versus 0.18 ± 0.48 (p = 0.036) (see Table 3).

View larger version (18K): [in this window] [in a new window]   Fig 2. . Survival after repair of left ventricular aneurysm using the linear repair ( LR) and the endoaneurysmorrhaphy (EA) techniques.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Late Results
We were unable to document a significant long-term survival advantage, but functional status was substantially better after endoaneurysmorrhaphy. This was achieved despite similar long-term medical management in both groups. Dor and co-workers [14] reported similar results 1 year after a circular repair, which is based on similar principles. In this study, we extended this observation to 3 to 5 years after the operation. The mechanism underlying the improvement in the functional class, which predominantly reflects the ability of the cardiovascular system to respond to exercise, is unclear. The assumption was that endoaneurysmorrhaphy results in a better geometric reconstruction with a smaller, more cone-shaped (less spherical) left ventricle, and therefore with less wall stress [5, 12–14]. Increased sphericity has been found to correlate with long-term clinical outcome in patients with a variety of cardiac disorders, such as myocardial infarction, idiopathic dilated cardiomyopathy, and mitral regurgitation [15–17]. Our study failed to confirm this hypothesis. We showed that years after operation, left ventricular volume and shape were very similar with both techniques, and were significantly larger and more spherical than those from a normal control group.

A more complete revascularization with endoaneurysmorrhaphy, particularly to the left anterior descending coronary artery, is another potential explanation for the better long-term functional results [12, 14]. In our study, there was no significant difference between the groups with respect to the number of patients who had concomitant revascularization, the average number of grafts per patient, and specifically the number of grafts to the left anterior descending artery. Thus, in our study, improved long-term functional results did not correlate with left ventricular volume and shape, the degree of myocardial revascularization, or long-term medical management. Other proposed mechanisms to explain this improvement in functional status after endoaneurysmorrhaphy have focused on improved and more symmetric synchronized contraction and relaxation in areas remote from the aneurysm, in particular adjacent to the border zone [18–20]. This study did not address these possibilities.

Limitations of the Study
This study was retrospective, with the two groups operated upon in series by several surgeons. However, there were no differences in the preoperative risk profiles and indications for operation, and the vast majority of the operations (40/47, 85%) were performed by the same surgeon (R.J.S.). Therefore, there were no significant differences between the groups with respect to operative technique, method of myocardial protection, cardiopulmonary bypass and aortic cross-clamp times, and the degree of myocardial revascularization. We believe that a comparison of outcomes between the groups is therefore valid. That the patients in the linear repair group had a longer follow-up compared with the endoaneurysmorrhaphy group is a true limitation of the study and could have influenced the late clinical results. It is possible that part of the improved functional status observed in the endoaneurysmorrhaphy group reflects the fact that patients in the linear repair group had a longer time to experience a decline in functional status. All of the previously published series evaluating "plastic" left ventricular reconstruction techniques have used retrospective data [5–14]. Undoubtedly, a prospective, randomized trial would provide much more definitive conclusions regarding the superiority of a particular technique.

Conclusion
Endoaneurysmorrhaphy was safe, and although the mechanism is not fully understood, it resulted in a greater increase in early postoperative left ventricular ejection fraction and better long-term functional results compared with linear repair. This study adds further support to the concept that "plastic" left ventricular reconstructive techniques for postinfarction aneurysm are superior to the linear repair method.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Shapira, Department of Cardiothoracic Surgery, Boston University Medical Center, 88 East Newton St, Boston, MA 02118 (e-mail: oshapira{at}acs.bu.edu).

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract 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): Oz M. Shapira Gabriel S. Aldea Richard J. Shemin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shapira, O. M. Articles by Shemin, R. J. Search for Related Content PubMed PubMed Citation Articles by Shapira, O. M. Articles by Shemin, R. J.