ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christiano Caldeira
Patrick M. McCarthy
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Caldeira, C.
Right arrow Articles by McCarthy, P. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Caldeira, C.
Right arrow Articles by McCarthy, P. M.
Related Collections
Right arrow Myocardial infarction

Ann Thorac Surg 2001;72:2148-2149
© 2001 The Society of Thoracic Surgeons

How to do it

A simple method of left ventricular reconstruction without patch for ischemic cardiomyopathy

Christiano Caldeira, MDa, Patrick M. McCarthy, MD*a

a Department of Thoracic and Cardiovascular Surgery, The Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication August 18, 2001.

* Address reprint requests to Dr McCarthy, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-25, Cleveland, OH 44195, USA
e-mail: mccartp{at}ccf.org


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
Interest in reconstructive surgery for ischemic cardiomyopathy has increased. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and three-dimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 References
 
Interest in reconstructive surgery for ischemic cardiomyopathy has increased as the heart failure population grows. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and three-dimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation [1].


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 References
 
Coronary artery bypass and mitral valve repair are performed during cardioplegic arrest, then left ventricular reconstruction (LVR) is performed on the beating heart. The LV apex is opened 2 cm lateral to the left anterior descending (LAD) artery through the thin-walled scar. The ventriculotomy is extended proximally for 4 to 6 cm. LV thrombus is removed. A basket sucker is placed inside the left ventricle if there is aortic insufficiency. If there is a discreet rim of subendocardial scar, it is excised down to the "border zone," the region where scar is contiguous with viable myocardium. For patients with a history of ventricular tachycardia, cryolesions are placed at the border zone.

The border zone is visible in dyskinetic infarcts, but in akinetic scars, palpation while the heart is beating is useful to identify the border zone. Two purse-string sutures of O polypropylene (on an MO-6 needle; Ethicon Inc, Somerville, NJ) are placed through the border zone 3 to 5 mm into the scarred tissue (Fig 1). Deep bites are taken into the scar tissue so that considerable tension can be applied. The first purse-string suture is tied, reducing the opening by 50% to 70%, creating a neck, usually 3 to 5 cm. The second purse-string suture is placed 5 mm above the first purse-string suture (Fig 1B), and when tied, the neck is usually less than 2 cm. The LV is reconstructed to more of an ellipsoid shape (not globular), the residual chamber is reduced, and the infarcted anterior wall and septum are excluded.



View larger version (33K):
[in this window]
[in a new window]
  		Fig 1. (A) The aneurysm is opened 2 cm left of the left anterior descending artery. Stay sutures aid exposure. A purse-string suture is placed along the border zone into the scarred tissue. Palpation of the border zone in akinetic ventricles is useful. (B) The first suture has been tied and a second purse-string suture is used to create a smaller neck.

 
Strips of felt are placed on the LV epicardium and secured with 2-0 polypropylene (on an MH needle; Ethicon Inc) as horizontal mattress sutures. The sutures are passed from the felt through the left ventricle at the level of the purse string sutures, then up the septum and out the LV wall left of the LAD (Fig 2A). Care is taken not to pass the sutures through the LAD or the right ventricle. The ventriculotomy is oversewn with 2-0 polypropylene to eliminate bleeding. During closure, the LV apex is elevated, air is evacuated, and a vent is present in the aortic root.



View larger version (37K):
[in this window]
[in a new window]
  		Fig 2. (A) Interrupted mattress sutures are passed through felt strips at the level of the purse-string sutures, then up to the left of the left anterior descending artery. (B) When visualized in cross-section, the anterior infarct is excluded, and the left ventricular chamber is surrounded by viable left ventricular muscle, with the exception of a thin rim of scar at the repair.

 
In cross-section, the anterior infarct is excluded and the reconstructed LV chamber is surrounded by viable LV muscle, with the exception of a thin rim of scar where the purse-string sutures were placed and reinforced with the mattress sutures (Fig 2B). The resultant LV chamber has no patch, and only a thin rim of noncontracting scar.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
References
 
Using a patch to reconstruct the LAD infarct substitutes a smaller akinetic area (the patch) for the original aneurysm [1–4]. Currently, we only use a patch in two situations: in patients with a calcified aneurysm in whom the purse-string sutures may not create a neck; and in rare patients with a small LV cavity that may be better reconstructed with a patch to avoid creating too small a cavity with a low stroke volume.

The no-patch technique was performed in 102 patients from April 1998 until November 2000. Hospital mortality was 1%.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Qin J.X., Shiota T., McCarthy P.M., et al. Real-time three dimensional echocardiographic study of left ventricular function after infarct exclusion surgery for ischemic cardiomyopathy. Circulation 2000;102(Suppl III):101-106.
  2. Jatene A.D. Left ventricular aneurysmectomy resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321-331.[Medline]
  3. Cooley D.A. Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm. J Cardiac Surg 1989;4:200-205.[Medline]
  4. Dor V., Saab M., Coste P., et al. Left ventricular aneurysm: a new surgical approach. J Thorac Cardiovasc Surg 1989;37:11-19.



This article has been cited by other articles:


Home page
 Interact CardioVasc Thorac SurgHome page
K. Toda, K. Taniguchi, and Y. Sawa
Left ventricular circumferential plication: novel off-pump ventricular restoration in swine model
Interact CardioVasc Thorac Surg, February 1, 2010; 10(2): 208 - 212.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
N. D. Patel, L. U. Nwakanma, E. S. Weiss, J. A. Williams, and J. V. Conte
Impact of Septal Myocardial Infarction on Outcomes After Surgical Ventricular Restoration
Ann. Thorac. Surg., January 1, 2008; 85(1): 135 - 146.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. B. Ratcliffe and T. S. Guy
The effect of preoperative diastolic dysfunction on outcome after surgical ventricular remodeling
J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 280 - 283.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
L. Menicanti, S. Castelvecchio, M. Ranucci, A. Frigiola, C. Santambrogio, C. de Vincentiis, J. Brankovic, and M. Di Donato
Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration
J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 433 - 441.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Cardiothorac SurgHome page
J. O. O'Neill, R. C. Starling, P. M. McCarthy, N. M. Albert, B. W. Lytle, J. Navia, J. B. Young, and N. Smedira
The impact of left ventricular reconstruction on survival in patients with ischemic cardiomyopathy
Eur J Cardiothorac Surg, November 1, 2006; 30(5): 753 - 761.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
P. Ferrazzi, M. L.S. Matteucci, M. Merlo, A. Iacovoni, G. Rescigno, M. Bottai, P. Parrella, L. Lorini, M. Senni, and A. Gavazzi
Surgical ventricular reverse remodeling in severe ischemic dilated cardiomyopathy: The relevance of the left ventricular equator as a prognostic factor
J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 357 - 363.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J. O. O'Neill, R. C. Starling, Y. Khaykin, P. M. McCarthy, J. B. Young, M. Hail, N. M. Albert, N. Smedira, and M. K. Chung
Residual high incidence of ventricular arrhythmias after left ventricular reconstructive surgery
J. Thorac. Cardiovasc. Surg., November 1, 2005; 130(5): 1250 - 1256.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
V. Dor
Left ventricular reconstruction: The aim and the reality after twenty years
J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 17 - 20.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
S. Schenk, P. M. McCarthy, R. C. Starling, K. J. Hoercher, M. D. Hail, Y. Ootaki, G. S. Francis, K. Doi, J. B. Young, and K. Fukamachi
Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy
J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 38 - 43.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
J. X. Qin, T. Shiota, P. M. McCarthy, C. R. Asher, M. Hail, D. A. Agler, Z. B. Popovic, N. L. Greenberg, N. G. Smedira, R. C. Starling, et al.
Importance of Mitral Valve Repair Associated With Left Ventricular Reconstruction for Patients With Ischemic Cardiomyopathy: A Real-Time Three-Dimensional Echocardiographic Study
Circulation, September 9, 2003; 108(2011): II-241 - II-246.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
P. M. McCarthy
Ventricular aneurysms, shock, and late follow-up in patients with heart failure
J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 323 - 325.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christiano Caldeira
Patrick M. McCarthy
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Caldeira, C.
Right arrow Articles by McCarthy, P. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Caldeira, C.
Right arrow Articles by McCarthy, P. M.
Related Collections
Right arrow Myocardial infarction

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS