Ann Thorac Surg 2000;70:1127-1129
© 2000 The Society of Thoracic Surgeons
Supplement: cardiothoracic techniques & technologies
Outcome of geometric endoventricular repair in impaired left ventricular function
Jai S. Raman, FRACSa,
Genichi Sakaguchi, MDa,
Brian F. Buxton, FRACSa
a Department of Cardiac Surgery, Austin and Repatriation Medical Centre, Heidelberg, Victoria, Australia
Address reprint requests to Dr Raman, Dept of Cardiac Surgery, Austin and Repatriation Medical Centre, Heidelberg, VIC 3084, Australia
e-mail: jraman{at}austin.unimelb.edu.au
Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeting 2000, Ft Lauderdale, FL, Jan 27–29, 2000.
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Abstract
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Background. Traditionally, repair of left ventricular aneurysms has been limited to patients with large localized ventricular aneurysms. Repair of dyskinetic segments in the setting of poor left ventricular function is still contentious.
Methods. Forty patients underwent geometric endo-ventricular repair, a new technique of ventricular aneurysm repair, over a 2-year period. Two groups of patients undergoing coronary artery bypass grafting (CABG) for left ventricular dysfunction in the same time period were reviewed. Group 1 comprised 23 consecutive patients who underwent geometric endo-ventricular repair along with CABGs, whereas group II consisted of 22 patients who underwent CABG alone.
Results. The early mortality was 9.1% in group I (1 cardiac, 1 noncardiac) and 0 in group II (NS). New York Heart Association class was remarkably improved from 3.4 to 1.4 (p < 0.05) in group I and to a lesser extent in group II (3.7 ± 0.5 versus 2.3 ± 0.5). Diastolic dimension of left ventricle was significantly reduced from 5.6 cm to 4.4 cm (p < 0.05) in group I and virtually unchanged in group II. There was one late death in each of the groups.
Conclusions. This technique of geometric left ventricular aneurysm repair is useful in patients with dyskinetic segments and may help in reducing cardiac size.
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Introduction
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Surgical resection of postinfarction dyskinetic aneurysms of left ventricle have been performed for many years since the first procedure was carried out by Likoff and Bailey [1]. Standard linear repair of left ventricular aneurysms (LVA) is widely accepted. Clinical results of this technique have been reported by many studies, but most of them failed to show satisfactory results in regard to early and late mortality [2–7]. Linear repair may distort the shape of left ventricular chamber. Recently, new methods of geometric left ventricular reconstruction have been proposed as a more physiologic repair [8]. Several retrospective studies comparing these two approaches to the repair of LVA in human patients showed that this new technique, which restores ventricular geometry, has a reduced overall mortality and is associated with better ventricular function [9–11]. This retrospective study evaluated the clinical results of geometric endoventricular repair (GER), which is a modification of the Dor endoventricular patch repair technique [8], and compared them with isolated coronary artery bypass grafting (CABG) operations in the patients with left ventricular dysfunction (LVD).
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Material and methods
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Between August 1997 and August 1999, 40 patients underwent GER for reconstruction of dyskinetic segments. Twenty-three consecutive patients with anteroseptal LVA underwent a GER associated with CABG and were labeled group I. Group II comprised 22 patients with large areas of myocardial scarring and LVD, who underwent the isolated CABG during the same period. Preoperative patient characteristics were shown in Table 1. There were 15 men and 8 women, with a mean age of 69 ± 7 years in the group I. Group II had a similar population with 16 men and 6 women, and a mean age of 70 ± 6 years. The mean New York Heart Association (NYHA) functional class was 3.4 ± 0.6 in the group I and 3.7 ± 0.5 in group II.
Operative technique
The procedure was performed using normothermic cardiopulmonary bypass. Cardiac standstill was achieved by a combination of antegrade and retrograde warm blood cardioplegia in both groups. After the cardiac arrest, the aneurysmal or dyskinetic segment was opened parallel to the left anterior descending artery. A circular bovine pericardial patch was cut to size such that its diameter was about one third of the diameter of the border zone. This patch was sutured to the border zone between the infarct scar and intact area with radially placed continuous 4-0 polypropylene sutures. This layer was reinforced by a second layer of radially placed sutures. The remnant of the resected scar was then closed in a linear fashion over the patch (Figs 1 to 3).
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Fig 1. Longitudinal section of a left ventricle with anterior scar. (X = diameter of the left ventricle at the border zone.)
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Fig 2. End-on view of the endoventricular patch implant. Note the radially placed sutures. (X/3 = size of the bovine pericardial patch approximately one third the diameter of the left ventricle at the border zone, x.)
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Fig 3. Longitudinal section of the left ventricle with patch implanted. Note the scar remnant covering the bovine pericardial patch.
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After the endoaneurysmorraphy, CABG was performed. The left internal mammary artery was grafted to the left anterior descending artery in all patients. The right internal mammary artery was used in 1 patient, the radial artery in 15 patients, and saphenous vein grafts in the remainder, to achieve complete revascularization. The mean number of grafts was 3.1 ± 0.9 in group I and 3.9 ± 0.9 in group II (p < 0.05). The mean aortic cross-clamping time was 87 ± 18 minutes in group I and 77 ± 13 minutes in group II. The mean cardiopulmonary bypass time was 122 ± 21 minutes in group I and 106 ± 13 minutes in group II (p < 0.05). These details are listed in Table 2.
Statistical analysis
The data are expressed as the mean ± standard deviation. The data were analyzed statistically by applying the paired or unpaired t test. A p value of less than 0.05 was considered significant.
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Results
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There was no significant difference between the two groups in preoperative patient characteristics (Table 1). There were two hospital deaths in group I and no deaths in group II. One patient died of cerebral infarction due to a spontaneous rupture of a plaque in the basilar artery. The other died 18 hours postoperatively due to overinfusion of fluid in a hypotensive and vasodilatory state. Postoperative hemodynamic measurements were recorded without any inotropic agents 20 to 24 hours after the operation (Table 3). There were no significant differences in cardiac index and pulmonary wedge pressure between the two groups. Postoperative echocardiographic measurements are also shown in Table 3. Left ventricle size was significantly reduced in the endoaneurysmorraphy group and ejection fraction was also significantly improved. Patients were followed up by telephone interview (mean, 13 months). There was one late death in each group. New York Heart Association class was significantly improved from 3.4 ± 0.6 to 1.43 ± 0.8 in group I and from 3.7 ± 0.5 to 2.3 ± 1.5 in group II. Recurrence of angina was noted in 1 patient in group I and 2 patients in group II.
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Comment
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This was a retrospective study and was not randomized in any way. The two study groups were similar, in that both groups had severe LVD with a measured ejection fraction of less than 35%. However, whereas patients in group I had reasonably localized dyskinetic segments, patients in group II were more heterogeneous. Some had large areas of akinesis, or patchy scarring. Most of the patients in group II were operated on by surgeons who were less aggressive in reconstructing dyskinetic segments. Therefore, although the comparison and results are interesting, definitive conclusions cannot be drawn. There was a trend toward better clinical results with GER, despite a slightly greater mortality. This study showed that GER of dyskinetic myocardial scars could reduce size of the left ventricle. This might contribute to the reduction of left ventricular wall stress and the improvement of cardiac function. Because NYHA class improved significantly after the operation and the risk of the endoaneurysmal repair was reasonable low in this series, this technique could be adapted easily for repair of the LVA or dyskinetic segments in patients with impaired left ventricular function with a reasonable chance of a good outcome. As other studies have suggested, complete revascularization is essential in these patients to achieve a good clinical outcome. The duration of cross-clamp was not long and suggests that GER may be easily added to a surgeon’s repertoire to achieve good early and long-term results.
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References
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Abstract
Introduction
