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Ann Thorac Surg 2005;80:537-542
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Absent Long-Term Benefit of Patch Versus Linear Reconstruction in Left Ventricular Aneurysm Surgery

^a Department of Cardiovascular Surgery, German Heart Center, Clinic at the Technical University, Munich, Germany
^b Institute of Medical Statistics and Epidemiology, Technical University, Munich, Germany

Accepted for publication March 3, 2005.

^_* Address reprint requests to Prof Dr Lange, Klinik für Herz- und Gefäßchirurgie, Deutsches Herzzentrum, Klinik an der Technischen Universität München, Lazarettstraße 36, D-80636 München, Germany (Email: lange{at}dhm.mhn.de).

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
BACKGROUND: Endoventricular patch reconstruction of the left ventricle is considered the gold standard in surgery for left ventricular aneurysms, because of improved preservation of ventricular geometry. However, the superiority over conventional linear closure has not been demonstrated, as assessed by the long-term outcome.

METHODS: Two hundred patients (66%) underwent linear closure (group L) and 105 patients (34%) had endoventricular patch reconstruction (group D) using the Dor technique. Linear closure has been performed since 1974 and from 1985 on the Dor technique has been applied as an alternative procedure. Both patient groups differed regarding age, sex distribution, site of infarction, and indication for surgery. Prior to the operation, 71% of the patients were in New York Heart Association (NYHA) class III or IV and mean ejection fraction was 34% ± 12%. Follow-up extends up to 25 years, with a cumulative total of 2,605 patient years.

RESULTS: Early mortality was 6.5% in group L vs 5.7% in group D (not significant [NS]). Actuarial survival after 10 years was 56 ± 3.2%, with no difference between groups. Freedom from reoperation after 10 years was 95.6% in group L vs 95.2% in group D (NS). Preoperative risk factors for late mortality were age, left ventricular enddiastolic volume index and concomitant mitral valve surgery. The type of procedure and the date of operation had no influence on mortality. To date, 63% of the survivors are in NYHA class I and II.

CONCLUSIONS: In regard to long-term survival, rate of reoperation, and postoperative NYHA functional class, no benefit could be demonstrated when linear closure was compared with ventricular patch reconstruction for LV aneurysm repair. Hence, the technique of ventricular reconstruction may not be as important as previously thought, and at least for small aneurysms the simple and time sparing technique of linear closure may still be considered.

	Introduction

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
Since the first resection of left ventricular aneurysm (LVA) reported in 1958 by Cooley and colleagues [1], various surgical techniques of LVA repair have been introduced with the aim of restoring left ventricular geometry in an effort to improve results [2, 3]). With all these techniques (conventional linear closure, endoventricular patch plasty, or endoaneurysmorrhaphy) a significant improvement in functional status can be achieved [4–8]. The impact of surgical technique on long-term results is discussed controversially. Some authors found no influence of surgical technique on operative mortality, long-term survival [9], and even functional and hemodynamic improvement [7, 9, 10]. Others could identify a lower hospital mortality and a better functional improvement in patients with endoventricular patch plasty [8, 9]. To determine the efficacy of LVA resection with different surgical techniques we retrospectively analyzed 305 patients with postinfarction LVA operated at our institution. The aim of the current study was to evaluate clinical results, to analyze operative and long-term survival, and to identify factors predicting operative mortality.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
We retrospectively analyzed 305 consecutive patients with LVA operated on between May 1974 and December 2000 at the German Heart Center Munich. In 200 of these (66%), linear resection with standard closure, as described by Cooley and colleagues, was performed (group L) [11]. One hundred and five (34%) patients underwent aneurysmectomy with endoventricular patch repair according to the technique described by Dor and colleagues [group D] (2). Linear closure has been performed since 1974 and the Dor technique was added as an alternative procedure in 1985. All operations were performed by a total of six surgeons. The two surgical techniques were used depending on the personal preference of each surgeon.

All patients had preoperative coronary angiography and left ventriculography an average 3.9 ± 4.0 months before the operation. Clinical symptoms, hemodynamic data, functional outcome, and survival rate were analyzed from medical records, patients follow-up visits, and communications from the referring physicians. In 78 (25.6%) patients, cardiac performance was assessed postoperatively by ventriculography. Congestive heart failure (CHF) was defined according to New York Heart Association (NYHA) functional class. The average age of the patients was 57 ± 9.6 years (range, 26.3 to 79.7 years). One hundred and twenty-six patients (41%) were older than 60 years. Two hundred and fifty-three (83%) were men and 52 (17%) were women [5:1]. Single indications for operation were angina in 38%, CHF in 30%, and severe rhythm disturbances in 7%. Eleven percent of the patients presented with a combination of symptoms. Congestive heart failure (40%) was the most frequent indication for surgery in group D, while angina (42%) was the most frequent in group L (p = 0.04) The site of infarction was anteroapical in 87% of the patients and posterior in 7.5%. Anteroapical infarction was more frequent in group L compared with group D (91% vs 79%); posterior infarction was more frequent in group D (11% vs 5.5%) (p = 0.01). The average interval between preoperative infarction and operation was 2.7 ± 4.3 years. Seven percent of the patients presented with left main disease, 23% had single-vessel disease, 32% had two-vessel disease, and 35% had three-vessel disease. Fifty-six patients (18%) had an incidence of sustained ventricular tachycardia or fibrillation preoperatively. Twenty-nine patients (9.5%) had undergone cardiopulmonary resuscitation. Seventy-one percent of the patients were in NYHA functional class III or IV. Diabetes mellitus was present in 18% of the patients, lipid abnormalities in 50%, hypertension in 39%, and a history of smoking in 39%. Preoperative clinical and hemodynamic data of the study groups are summarized in Table 1 and Table 2, respectively.

Associated procedures included intraoperative electrophysiologic studies and cryotherapy in 6 patients who had documented preoperative ventricular tachycardia or fibrillation, ventricular septal defect (VSD) closure in 11 patients, mitral valve replacement in 6, mitral valve repair in 3, and aortic valve replacement in 3 patients. There was no significant difference in the need for additional procedures such as VSD closure and mitral valve surgery between both patient groups. In 63 patients a mural thrombus attached to the endocardial surface was removed with the resection of the aneurysm.

Two hundred and seven patients (68%) underwent associated coronary grafting with a mean number of 1.5 ± 1.4 bypass grafts. The average number of grafts did not differ between patient groups. Associated coronary artery bypass grafting (CABG) was performed in 65% of the patients in group L and 73% of group D, respectively (not significant [NS]). The internal mammary artery was used for grafting in 29% of the group D patients compared with 11% in group L (p = <0.001). Repair of LVA alone was performed in 98 patients (32%). The cardiopulmonary bypass time was 97 ± 46 minutes (group L [82 ± 36 min]) and group D (124 ± 47 min) (p = 0.001)]. Twelve percent of the patients were operated on an emergency basis. Intraaortic balloon pump was inserted postoperatively in 19 patients because of low cardiac output. Operative data are summarized in Table 3. Patients spent an average of 4.3 ± 2.9 days in the intensive care unit (ICU). Mean length of hospital stay was 16.7 ± 8.7 days.

View larger version (16K): [in this window] [in a new window]   Fig 1. Linear closure versus Dor technique. Preoperative (white bars) and postoperative (black bars) New York Heart Association functional class in 128 survivors after left ventricular aneurysm resection. The height of the column indicates the percentage of patients.

	Results

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
The overall 30-day mortality was 6.2%. In group L, 13 (6.5%) patients died early compared with 6 (5.7%) in group D. One hundred and fifty-eight patients (52%) died late after an average 7.5 ± 5.8 years. Overall actuarial survival after 10 years was 56 ± 3.2%. Patients in group L showed a 10-year actuarial survival rate of 55.5% compared with 55.4% in group D (p = 0.48) (see Fig. 2). Operative and late mortality were mainly due to cardiac failure. There were no significant differences in postoperative complications between the groups. Cox regression revealed older age, higher left ventricular enddiastolic volume (LVEDV), and concomitant mitral valve surgery as significant risk factors for late mortality. Other parameters such as sex, type of procedure, date of operation, LV ejection fraction less than 25%, preoperative NYHA functional class, site of infarction, indication for surgery, and concomitant CABG had no significant influence on mortality. There was also no difference in long-term survival between patients with and without concomitant CABG (p = 0.97). The LVEDV index was significantly higher in group D (146 ± 41 mL/m²) compared with group L (133 ± 49 mL/m²) (p = 0.031). Site of infarction and indication for surgery also differed in both patient groups. No significant differences between both patient groups were found regarding preoperative NYHA functional class, LV ejection fraction, left ventricular enddiastolic pressure, preoperative ventricular tachycardia-fibrillation, and type of coronary artery disease.

View larger version (16K): [in this window] [in a new window]   Fig 2. Linear closure versus Dor technique. Kaplan-Meier estimate of survival function for 305 patients with left ventricular aneurysm undergoing linear resection (continuous line) or endoventricular patch plasty (dotted line).

	Comment

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
Ten percent to 35% of patients who have had transmural myocardial infarction develop a ventricular aneurysm [13]. Studies on the natural history of LV aneurysms report a 5-year survival of only 12% to 47% [14, 15]. Since the late 1950s, when LVA resection under cardiopulmonary bypass was first performed, survival has improved considerably. Jatene and colleagues [3] reported a reduction in operative mortality from 12.6% to 3.5% in a series of 508 patients who underwent circular reduction and closure with or without a prosthetic patch. Newer surgical techniques of LVA repair, with the aim of restoring left ventricular geometry, proved to be valuable even in patients with severely impaired left ventricular function [1, 16, 17]. However, there is an ongoing debate regarding the influence of surgical technique on long-term survival.

This report reviews our experience with different methods of LVA repair. Beginning in 1974, linear closure of LVA was the technique of choice. Since 1985 the technique described by Vincent Dor has been applied as an alternative method. At our institution, overall operative mortality was 6.2% and 10-year survival was 56 ± 3.2%. Our results compare favorably with those of other authors who report an operative mortality between 3.5% and 8% and a 10-year survival between 44% and 63% [3, 7, 9, 16]. Comparing the outcome in patients with linear closure and patch reconstruction, no significant difference in operative mortality and long-term survival was found. This confirms results of other authors [7, 9]. Both patient groups in our study were comparable regarding the preoperative NYHA functional class, ejection fraction (EF), left ventricular enddiastolic pressure and the extent of coronary artery disease. However, those patients who underwent the Dor procedure were usually older and the percentage of female patients was higher. Komeda and colleagues [16] also found no influence of the technique of LVA repair on operative mortality. However, when analyzing a subgroup of patients with impaired LV function (LVEF < 20%), they found that the operative mortality after conventional closure versus inverted T closure or endocardial patch repair differed significantly (12.6% vs 6.5%). In a series of 118 patients with LVA analyzed by Sinatra and colleagues [8], none of the patients who had endoventricular patch plasty died in the hospital. Hospital mortality in those patients who underwent linear closure was 10.3%.

Various authors [16, 18] underlined the importance of concomitant complete revascularization in patients with LVA. Right ventricular dysfunction is common after repair of LVA and Komeda and colleagues [16] therefore strongly recommend revascularization of the right coronary artery. Sixty-eight percent of our patients underwent concomitant bypass grafting. However, there was no statistical difference in survival between patients with or without CABG. Vural and colleagues [9] had similar results.

Different risk factors for operative and late mortality have been investigated [18, 19]. Komeda and colleagues [16], analyzing 336 patients operated with different surgical techniques, identified poor left ventricular function (EF < 20%), age greater than 60 years, previous myocardial revascularization, lack of angina pectoris, and NYHA functional class IV as independent predictors of operative mortality. The presence of left main coronary artery stenosis was a predictor of late mortality after repair of LVA. Nonanterior location of myocardial infarction and a history of thromboembolic event were independent risk factors for overall mortality in a recent study [7]. The presence of a posterior aneurysm is associated with a higher mortality and those patients come to the operation in a more compromised state. In our series we could identify age, left ventricular enddiastolic volume index, and concomitant mitral valve surgery as significant risk factors for late mortality. The type of procedure and the date of operation had no influence on mortality.

Various studies showed a significant clinical and hemodynamic improvement after LVA resection with different surgical techniques [4, 5, 20]. Dor and colleagues [6] demonstrated a significant increase in ejection fraction and a reduction in ventricular volume, as well as an improvement in NYHA functional class. Patients who benefit most from the operation are those with more severe preoperative ventricular dysfunction (EF < 30%). Patients who did not have a satisfactory improvement of EF were more likely to have multivessel disease and, in particular, critical involvement of the right coronary artery [6]. Vural and colleagues [9] found a better functional improvement in patients with circular patch closure. We could also demonstrate a subjective and objective improvement in functional status; however, there was no significant difference between the patient groups.

Study Limitations
The present investigation is performed as a retrospective nonrandomized analysis. We compared two different surgical techniques for LVA repair. Linear closure has been performed since 1974 and in 1985 the Dor technique was added as an alternative procedure. Patients in the linear repair group had a longer follow-up and the sample sizes of both patient groups L and D were different. This might have influenced the late clinical results. On the other hand, only a few studies with a 25-year follow-up are available. A prospective randomized trial would obviously provide more definitive conclusions regarding the superiority of a particular technique. However, with the number of LVA decreasing this might be achieved only in a multicenter study.

Conclusion
The LVA resection is a definite procedure with a low reoperation rate and can be performed with low operative mortality even in severely compromised patients. The clinical status of the patients improved significantly. In regard to the long-term survival and the reoperation rate we could not demonstrate a difference related to the surgical technique. With both surgical techniques comparable results regarding operative mortality, improvement in clinical status, and survival can be achieved. In regard to long-term survival, rate of reoperation, and postoperative NYHA functional class, no difference could be demonstrated when linear closure was compared with ventricular patch reconstruction for LVA repair. Hence, the technique of ventricular reconstruction may not be as important as previously thought, and at least for small aneurysms, the simple and time sparing technique of linear closure may still be considered.

	Discussion

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
DR SARA SHUMWAY (Minneapolis, MN): Did you have to manage ventricular tachycardias in these patients perioperatively and was that an issue in a certain percentage of the patients and did any patients require pacemakers postoperatively?

DR GUENTHER: Thank you very much. Thirty-seven patients, 12% of the whole group, presented with ventricular tachycardia, six patients underwent mapping and cryotherapy, and nine patients required an ICD postoperatively.

DR SHUMWAY: Pacemaker?

DR GUENTHER: Seven patients required a pacemaker.

DR SHUMWAY: And were the patients who got cryotherapy in the older group?

DR GUENTHER: There was no difference in ventricular tachycardias between both patient groups.

DR RAUL GARCIA-RINALDI (Mayaguez, PR): Can you please explain how you do your linear closure? Since 1996, we have done a primary closure without pledgets. We have done very well from the standpoint of hemostasis. Can you please explain how you do it?

DR GUENTHER: Well, after aneurysmal resection we use two Teflon felt strips and a mattress suture and a second over-and-over row to close it.

DR ROBERT DION (Leiden, the Netherlands): I would like to ask you about the extent of the septal involvement in these cases. Indeed you merely classified the patients according to the site of the infarction, anterior or inferior, without describing the extent of the septal scar. The advantage of the endocardial patch repair over the linear repair is precisely that you can exclude even a huge septal scar from the residual left ventricular cavity. Did the presence of an extensive septal scar influence your technique of repair? If it did, this introduced a bias in your comparison. Did you systematically exclude the septal scar when you used the patch repair? If you did not, I believe that you did not take the maximal benefit out of this technique.

DR GUENTHER: Thank you very much. This question is difficult to answer. All the operations have been performed by six surgeons, and we started to use the Dor technique in 1985, and the use of the technique was due to the preference of the surgeon, first. I don’t have enough data to answer your question regarding the involvement of the septum. Obviously, this is one of the advantages of the Dor technique: you can exclude the scar at the septum.

DR LAWRENCE BONCHEK (Lancaster, PA): My question is one more of medical history than surgical technique. I am just wondering why you refer to this as the Dor technique rather than the patch technique? While Vincent Dor certainly deserves all the credit in the world for drawing our attention to ventricular remodeling in patients with heart failure, for patients with aneurysms Denton Cooley described this technique long ago and called it endoaneurysmorrhaphy. Adib Jatene also popularized it. So I would just make a plea for giving credit where credit is due.

DR GUENTHER: I have no comment on that. Thank you very much.

	References

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This Article Abstract Full Text (PDF) 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): Ruediger Lange Thomas Guenther Norbert Augustin Hans Meisner Klaus Holper Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lange, R. Articles by Holper, K. Search for Related Content PubMed PubMed Citation Articles by Lange, R. Articles by Holper, K.