Ann Thorac Surg 2006;81:1495-1497
© 2006 The Society of Thoracic Surgeons
Case report
Reconstruction of the Left Ventricle After Previous Aneurysmectomy
Arjun D. Koch, MDa,
Eduard R. Holman, MDb,
Michel I.M. Versteegh, MDa,
Robert J.M. Klautz, MD, PhDa,
Suresh T. Somer, MDb,
Jeroen J. Bax, MD, PhDb,
Robert A.E. Dion, MD, PhDa,*
a Department of Cardiothoracic Surgery Leiden, the Netherlands
b Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Accepted for publication April 25, 2005.
* Address correspondence to Dr Dion, LUMC, Department of Cardio-thoracic Surgery, Albinusdreef 2, PO Box 9600, Leiden, 2300 RC, the Netherlands (Email: r.a.e.dion{at}lumc.nl).
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Abstract
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Two patients recently underwent successful repeat left ventricular anterior aneurysmectomies at our institution. Both patients had undergone a linear repair at first operation. Over time severe heart failure relapsed and echocardiography revealed the recurrence of a voluminous antero-septo-apical aneurysm in both cases, associated with severe mitral regurgitation. Because of still preserved motion of at least three of the basal segments of the left ventricle, a repeat ventriculoplasty according to Dor and a restrictive mitral valve annuloplasty was attempted. At 6-month follow-up, the patients were in the New York Heart Association functional class I and II, respectively. Left ventricular end-diastolic diameters decreased from 73 mm to 67 mm and from 81 mm to 52 mm, and left ventricular end-systolic diameters from 61 mm to 54 mm and from 70 mm to 34 mm. Mitral regurgitation was absent.
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Introduction
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Various techniques of aneurysmectomy aiming at restoration of the geometry of the left ventricle have been reported that can be roughly divided into linear and circular repairs [1, 2]. Theoretically, redo left ventricular aneurysmectomy is feasible, but data are scarce. We describe 2 patients undergoing successful redo left ventricular aneurysmectomies using the Dor endoventricular patch plasty [3].
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Case Reports
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Patient 1
The first patient, a 70-year-old man, suffered an anterior wall infarction followed by formation of an antero-apical aneurysm. In 1983, he underwent a linear repair of this aneurysm and received saphenous vein grafts to the circumflex and the posterior descending artery. In 2001 he had progressive congestive heart failure and angina pectoris developed. Heart catheterization revealed occlusion of both grafts and a severely depressed left ventricular function with a large antero-septo-apical aneurysm without any definite borders. The antero-basal and the proximal part of the postero-basal segments displayed an acceptable contractility. The left ventricular ejection fraction was 16%. Two-dimensional echocardiography confirmed the catheterization data and precised that only the basal part of the septum was contracting. Left ventricular end-diastolic and end-systolic diameters were 73 and 61 mm, respectively, and there was a grade 3 mitral regurgitation (MR) (Carpentier type I and IIIb). At reoperation on June 19, 2002, a large endoventricular extension of the scar was observed on the septum, with scar tissue that extended to 1 cm below the aortic valve; it extended on the free wall to the base of the posterior papillary muscle and involved the anterior papillary muscle. The left ventricle was reconstructed according to Dor [3], the residual cavity being calibrated using a Fontan stitch and a saline filled balloon (55 mL/m2 body surface area). The residual gap was closed with an oval shaped Dacron patch (25 x 15 mm) (Hemashield, Meadox Benelux BV, Huizen NL). Restrictive mitral valve annuloplasty was performed using a 26 (instead of 30) Physioring (Carpentier-Edwards, Irvine, CA). Concomitant myocardial revascularization consisted of a left internal mammary artery graft to the very proximal left anterior descending coronary artery and a saphenous vein graft to two circumflex branches and the posterior descending artery. Intraoperative transesophageal echocardiography showed no residual MR, with a coaptation length of 9 mm and a mean gradient of 3 mm Hg, and a much improved systolic function. The patient needed inotropic support and intraaortic counterpulsation for 2 days and transient haemodialysis. Further recovery was uneventful, and the patient was discharged on postoperative day 19. At 6-month follow-up, the patient was in New York Heart Association’s functional class I. At 2-dimensional echocardiography the left ventricular end-diastolic diameter improved from 73 mm to 67 mm and the left ventricular end-systolic diameter from 61 mm to 54 mm. The angiographic left ventricular ejection fraction improved to 31%. Mitral regurgitation was absent. To date his clinical condition remains stable.
Patient 2
The second patient, a 72-year-old man, had a history of anterior wall infarction in January 1994, followed by formation of a large antero-apical aneurysm and extensive three-vessel disease. He underwent a linear repair and concomitantly received a left internal mammary artery graft to the left anterior descending coronary artery, and a sequential saphenous vein graft to the circumflex (x2) and posterior descending arteries. A few years later he redeveloped class IV congestive heart failure. A heart catheterization showed patent grafts and a recurrent antero-apical aneurysm (Figs 1A,
1B). Two-dimensional echocardiography showed a large antero-septo-apical aneurysm with a dilated left ventricle and moderate MR (Carpentier type I and IIIb). The left ventricular ejection fraction was 18%. Because of a wide QRS complex with left bundle branch block configuration, atrio-biventricular pacing was installed [4]. Symptoms did not improve and echocardiography still revealed a large antero-septo-apical aneurysm with a left ventricular end diastolic diameter of 81 mm, and a left ventricular end systolic diameter of 70 mm. However, the basal anterior, inferior, septal, and lateral segments still exhibited systolic function. There was a grade 3 mitral and tricuspid regurgitation. At reoperation on April 2002, endoventricular involvement extended to 4 cm below the aortic valve on the septum, to 1 cm below the papillary muscle on the lateral wall and onto the distal half of the inferior wall. The ventricle was reconstructed according to Dor [3], the residual cavity being calibrated using a Fontan stitch and a saline filled balloon (55 mL/m2 body surface area). The residual gap was closed with a Dacron patch (20 x 15 mm). Also, a restrictive mitral valve annuloplasty was performed using a 28 (instead of 32) Physioring (Carpentier-Edwards). Tricuspid annuloplasty was performed using a 30 MC3 ring (Edwards Lifesciences, Irvine, CA). Intraoperative transesophageal echocardiography showed no residual MR, with a coaptation length of 8 mm and a mean gradient of 3 mm Hg. The patient needed inotropic support and an intraaortic balloon pump for 2 days. He was discharged from the hospital on postoperative day 17. At 6 months he was in New York Heart Association’s functional class II. At two-dimensional echocardiography, his left ventricular end diastolic diameter had decreased from 81 mm to 52 mm, and his left ventricular end systolic diameter had decreased from 70 mm to 34 mm. There was no residual MR; this was confirmed at ventriculography (Figs 1C, 1D) and his left ventricular ejection fraction was 37%. To date his clinical condition remains stable.
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Fig 1. Preoperative and postoperative left ventricular (LV) angiography of patient 2. (Panels A and B): preoperative recurrent apical aneurysm. (A) End-diastolic frame. (B) End-systolic frame. (Panels C and D): postoperative LV aneurysmectomy. (C) End-diastolic frame. (D) End-systolic frame; disappearance of the LV aneurysm.
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Comment
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Recurrence of left ventricular aneurysm may result from a recurrent myocardial infarction, but probably more frequently from an incomplete exclusion of the scar tissue at the first operation, with a suboptimal reduction of wall stress. The Dor technique allows the exclusion of all the infarcted endocardial areas and a precise geometrical reconstruction. In the present report, a significant improvement in clinical echocardiographic and angiographic measurements was achieved after redo aneurysmectomy using the Dor technique and restrictive mitral valve annuloplasty. Two-dimensional echocardiography confirmed reduction in the left ventricular dimensions, improvement of left ventricular function, and absence of mitral regurgitation. Before indicating redo aneurysmectomy we believe that we should respect our criteria used to indicate a primary aneurysmectomy in overt heart failure; at least three of the four basal segments (septal, lateral, anterior, inferior) should exhibit adequate contractility. In presence of depressed left ventricular function, MR (even moderate) should be corrected by means of a restrictive mitral valve annuloplasty (two sizes down), and severe MR is not a contraindication as recently published by our group [5].
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References
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- Cooley DA, Collins HA, Morris GC, Chapman DW. Ventricular aneurysm after myocardial infarction. surgical excision with use of temporary cardiopulmonary bypass. JAMA 1958;167:557-560.[Abstract/Free Full Text]
- Jatene AD. Left ventricular aneurysmectomy. Resection or reconstruction J Thorac Cardiovasc Surg 1985;89:321-331.[Medline]
- Dor V. The endoventricular circular patch plasty ("Dor-procedure") in ischemic akinetic dilated ventricles Heart Failure Reviews 2001;6:187-193.[Medline]
- Auricchio A, Stellbrink C, Block M, et al. Guidant Congestive Heart Failure Research Group Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure Circulation 1999;99:2993-3001.[Abstract/Free Full Text]
- Braun J, Bax JJ, Versteegh MIM, et al. Preoperative left ventricular dimensions predict reverse remodeling following restrictive mitral annuloplasty in ischemic mitral regurgitation Eur J Cardiothorac Surg 2005;27:847-853.[Abstract/Free Full Text]
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Abstract
Introduction
