Ann Thorac Surg 2001;72:S1055-S1058
© 2001 The Society of Thoracic Surgeons
Supplement: Cardiothoracic techniques and technologies
Geometric endo-ventricular patch repair of inferior left ventricular scars improves mitral regurgitation and clinical outcome
Jai Raman, FRACSa,b,
Anand Dixit, FRACSa,b,
Meg Storer, BN(Hons)a,b,
David Hare, FRACPa,b,
Brian F. Buxton, FRACSa,b
a Department of Cardiac Surgery, Austin & Repatriation Medical Centre, Melbourne, Australia
b Department of Cardiothoracic Surgery, Royal Hobart Hospital, Hobart, Australia
Address reprint requests to Dr Raman, Department of Cardiac Surgery, Austin & Repatriation Medical Centre, Heidelberg, Melbourne, Victoria 3084, Australia
e-mail: jai.raman{at}armc.org.au
Presented at the Seventh Annual Cardiothoracic Techniques and Technologies Meeting 2001, New Orleans, LA, Jan 24–27, 2001.
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Abstract
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Background. The surgical reconstruction of inferior left ventricular (LV) aneurysms and scars has been considered a difficult procedure and there has been little material published about this treatment option. In this study we report on our experience with reconstruction of the inferior wall and compare it to the outcome of anterior LV reconstructions.
Methods. Seventeen patients (group 1) underwent geometric endo-ventricular patch repair (GER) of inferior LV aneurysms and dyskinetic scars between January 1998 and December 2000. In addition to poor LV function, 5 of these patients had severe mitral valve regurgitation (MR), 8 had moderate MR, and 4 had mild MR preoperatively. These patients also underwent coronary artery bypass graft surgery or valve surgery. The perioperative course, survival, and clinical status were evaluated in this group and was compared to those of 86 patients (group 2) undergoing anterior GER during the same period.
Results. There was 1 early death in group 1 (5.8%) and 6 in group 2 (7%) (p = ns). At the conclusion of the operative procedure, all patients in group 1 were weaned off cardiopulmonary bypass with trivial to mild MR. There was 1 late death in group 1 (6.2%) and 2 in group 2 (2.8%) (p = ns). Eleven patients (73%) in group 1 were in New York Heart Association class 1 compared to 60 in group 2 (77%) (p = ns). Follow-up echocardiography showed that 80% of patients in group 1 had trivial MR.
Conclusions. The surgical reconstruction of inferior LV aneurysms and scars can be performed safely with the expectation of a reasonable early outcome similar to that achieved with anterior LV scars. When used in this setting GER improves MR, reducing the likelihood of heart failure decompensation.
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Introduction
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Inferior left ventricular scars that are aneurysmal or dyskinetic are often not repaired, partly because of the risk of injury to the posterior papillary muscle or the mitral annulus but more often because it is difficult access the inferior part of the ventricle [1]. The association between inferobasal dyskinetic scars and mitral regurgitation is not well known despite having been elegantly described by Gorman and colleagues [2] and Levine and associates [3]. Patients presenting for coronary artery surgery with moderate mitral regurgitation in the presence of normal-looking mitral valve leaflets can pose dilemmas in operative management. Repair of dyskinetic inferior scars have been described [4, 5] but are uncommon [6]. Mitral regurgitation of a moderate degree has also been suggested as a predictor of a poor long-term prognosis [6]. We reviewed our experience with this technique and examined the degree of mitral regurgitation (MR) present in these patients. We then compared their clinical outcome and functional status with those of a group of patients undergoing antero-septal left ventricular reconstructions.
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Material and methods
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Between January 1998 and December 2000, 17 patients underwent repair on left ventricular scars as an adjunct to coronary artery surgery (n = 16) and aortic valve surgery (n = 1). These patients were assigned to group 1. Five of these patients had moderately severe MR, 8 had moderate MR, and 4 had mild MR. All patients had some impairment of left ventricular function. The mean preoperative ejection fraction was 28%. Five patients had surgery on an urgent basis and 1 patient had emergency surgery.
Group 2 consisted of 86 patients who underwent geometric endo-ventricular repair (GER) of anterior and anteroseptal left ventricular scars during the same period using a method described previously [7]. Only 1 of these patients had a significant inferobasal dyskinetic segment in addition to the anterior scar that required repair. Mitral regurgitation was of moderate severity in 9 patients. Patients who underwent mitral valve repair or replacement for severe mitral regurgitation were excluded from this group. The mean preoperative ejection fraction was 27%. A total of 18 patients (21%) had urgent surgical intervention and 84 (97%) had concomitant coronary artery bypass graft surgery.
Surgical technique
Aortic and single venous cannulation were performed in all patients. Blood cardioplegia was administered at frequent intervals, both in an antegrade fashion through the aortic root and in a retrograde fashion through the coronary sinus.
In group 1 the aneurysm was opened with a linear incision parallel to the septum approximately 1 cm lateral to the posterior descending artery. The edges of the scar and the border zone were identified. An oblong or oval patch roughly one third of the long-axis size of the defect at the border zone was cut to measure (ie, the patch tended to be lengthwise along the long axis of the posterior descending artery, and the length of the patch was about one third of the axial dimension of the border zone). The patch was then implanted endo-ventricularly using a continuous 4-0 Prolene (Ethicon, Somerville, NJ) suture. Figure 1 shows schematically the steps involved in the reconstruction of the inferior left ventricular wall. The scar remnants were then closed over the patch with simple over-and-over 4-0 Prolene sutures. This technique has elements of the repair described by Mickleborough [5] but differs by suggesting a rough guide for judging the patch dimension. It also uses the patch to reconstruct the whole defect instead of advocating a modified linear closure, which can distort the inferior wall significantly, and it avoids the use of Teflon felt strips. When required, complete surgical revascularization was performed. One patient had an Alfieri edge-to-edge type repair of the mitral valve through the inferior scar without the use of a ring.
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Fig 1. Steps of repair. (a) shows area of dyskinesis on the inferior wall of the left ventricle, lateral to the posterior descending artery (PDA); (b) scar opened up lateral to posterior descending artery with a small oval patch measuring roughly one-third the size of the defect in the long-axis; (c) bovine pericardial patch being implanted with radially placed sutures within the ventricle.
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In group 2, 84 (97.6%) of the patients underwent coronary artery bypass graft surgery. One of these patients had plication of an inferior scar from within, after resection of the anterior scar. He was not included in group 1 because of the type of repair.
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Results
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Group 1
One patient undergoing urgent redo coronary artery bypass graft surgery who had a large dyskinetic inferior scar and a moderately large akinetic anterior scar died perioperatively (5.8%). This patient had profound hypotension on cardio-pulmonary bypass, which was mildly responsive to large doses of noradrenaline. Postoperatively, despite reasonable cardiac contractility, the systolic blood pressure could not be raised to more than 75 mm Hg, in spite of large doses of adrenaline, noradrenaline, and metaraminol. There was also 1 late respiratory death in a patient who had chronic obstructive airways disease.
Transesophageal echocardiography revealed an improvement in mitral regurgitation and left ventricular function in all patients. Clinical and echocardiographic follow-up was complete in the 15 survivors at a mean duration of 510 days. Twelve patients (73%) were in New York Heart Association (NYHA) functional class I.
Figure 2 graphically depicts the change in functional status after surgery. Figure 3 shows the change in the degree of mitral regurgitation.
Group 2
There were 2 perioperative cardiac deaths (2.3%), 3 neurologic deaths (3.5%), and 1 death due to gut ischemia, giving a total hospital mortality of 7% in the anterior GER group. There were 2 late deaths, 1 due to sudden death and 1 due to lung cancer. In all, 60 of the surviving 77 patients (78%) were in NYHA functional class I at a mean follow-up of 536 days.
Differences between groups
Although the groups were different in terms of absolute numbers, we chose to compare them to assess early and intermediate outcomes of repair of inferior scars versus those of anterior left ventricular reconstructions. The two groups were compared purely for clinical outcome and functional status. There was no significant difference between the two groups in terms of operative mortality, late death, or functional status.
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Comment
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There are few clinical reports of the outcome of repair of inferior left ventricular aneurysm or scars [4, 6]. D’Or [8] described the technique of repair of inferior and posterior aneurysms while alluding to the association between posterior aneurysms and refractory ventricular tachycardia [9, 10].
Patients with poor left ventricular function and mitral regurgitation are considered to be at high risk and often are not offered surgery. The repair of inferior left ventricular aneurysms and dyskinetic inferior left ventricular scars represents a gray zone in cardiac surgery. There are few clear-cut guidelines for handling these patients, presumably because of their relative rarity. In the presence of left ventricular dilatation in association with poor systolic function, mitral regurgitation often acts as a decompensating mechanism. Bolling and colleagues [11] have advocated using radical mitral annuloplasty in this group of patients after decompensation and have had encouraging results. However, the cause of the mitral regurgitation in these patients is more complex than simple annular dilatation. Levine and associates [3] have shown quite conclusively that inferobasal dykinesis plays a significant part in the mechanism of mitral regurgitation, whereas the pathogenesis of tachycardia induced cardiomyopathy in animals is primarily annular dilatation [12]. In patients with inferobasal aneurysms, mitral regurgitation coexists and is often significant. Figure 4 illustrates the mechanism of mitral regurgitation in the presence of inferior left ventricular dyskinetic scars, as proposed by Levine and associates.
This report suggests that repair of inferior left ventricular scars can be achieved safely with reasonable clinical outcomes. There is a potential of effectively treating the coexisting mitral regurgitation. Figure 5 demonstrates how patch repair may promote coaptation of mitral valve leaflets, thereby correcting mitral regurgitation.
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Fig 5. Illustration of how patch repair of inferior aneurysm may promote coaptation of mitral valve leaflets and reducing mitral regurgitation.
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References
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Gorman R.C., McCaughan J.S., Ratcliffe M.B., et al. Pathogenesis of acute ischemic mitral regurgitation in three dimensions. J Thorac Cardiovasc Surg 1995;109:684-693.[Abstract/Free Full Text]
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Liel-Cohen N., Guerrero J.L., Otsuji Y., et al. Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation 2000;101:2756-2763.[Abstract/Free Full Text]
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Mickleborough L.L., Maruyama H., Liu P., Mohamed S. Results of left ventricular aneurysmectomy using a tailored scar incision and primary closure technique. J Thorac Cardiovasc Surg 1994;107:690-698.[Abstract/Free Full Text]
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Mickleborough LL. Left ventricular aneurysm: modified linear closure technique. Operative Techniques in Cardiac & Thoracic Surgery. Cox JL, Sundt TM, eds. 1997;2:118–31.
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Mickleborough L.L., Carson S., Ivanov J. Repair of dyskinetic or akinetic left ventricular aneurysm: results obtained with a modified linear closure. J Thorac Cardiovasc Surg 2001;121:675-682.[Abstract/Free Full Text]
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Abstract
Introduction
