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SURGICAL MANAGEMENT OF LEFT VENTRICULAR ANEURYSM AS A COMPLICATION OF ACUTE MYOCARDIAL INFARCTION - A SINGLE SURGEON EXPERIENCE
Abstract
Left ventricular aneurysm is a localized area of the myocardium, with abnormal outward bulging and deformation during systole and diastole, which may be an akinetic, dyskinetic hypokinetic segment. It is due to the weakening of the muscle wall. The aim of this study is the assessment of the Left Ventricular aneurysm, its clinical presentation, Repair technique, and surgical outcome of patients presented with Acute Myocardial infarction with Ventricular wall complications. A retrospective study of the case scenarios that have undergone LV aneurysm repair in a tertiary care hospital facility over four years (2015-2019) after being diagnosed with Acute and evolved Myocardial infarction, which has been rehabilitated by medical management and then referred from cardiology. The Cases with aneurysm were diagnosed by 2d- echocardiography, examined for window period, taken up for surgery, which is re-vascularisation and surgical ventricular remodeling. Of the 6 cases operated, the results were as follows. The mean age of presentation is early for patients with co-morbidities like diabetes and hypertension. Female preponderance is seen. Habitual alcohol consumption causes an early presentation of symptoms. Severe LV dysfunction due to occlusion of the Left coronary artery causes this aneurysm. The most frequent site of aneurysm is the anterior wall with an apex. Apex or Distal anterior wall involvement is repaired by Dor or Linear repair. A septal aneurysm is repaired by septal exclusion by linear Dacron. To conclude, acute MI due to Single or Triple vessel disease can lead to LV aneurysm, which can be Akinetic or Dyskinetic segment.LV Aneurysm as a complication can have a varied presentation, including an Anterior wall, Apex, Apex, and variable extent of the septum and posterior wall, with varied ventricular function with organic valvular MR or Functional MR. Patients with Hypertension and Habitual alcohol consumption have an early age of presentation
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Objective:
This study was performed to analyze and compare the efficacy of three treatment methods for left ventricular aneurysm (LVA): coronary artery bypass grafting (CABG) combined with left ventricular resection, drug treatment, and percutaneous coronary intervention (PCI).
Methods:
In total, 183 patients with LVA from Fuwai Hospital were divided into three groups according to the treatment method: 51 patients underwent left ventricular resection combined with CABG (CABG-resection group), 65 underwent drug treatment (drug group), and 67 underwent PCI (PCI group). The clinical characteristics and survival rates of the patients were compared among the three groups.
Results:
The patients' basic data and medical history were analyzed. The postoperative left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were significantly higher than those before surgery, indicating that the left ventricular function markedly improved after the operation.
Conclusion:
Surgery is recommended as the first treatment option for LVA, and conservative therapy can be considered for selected patients. Although the difference was not statistically significant, CABG with left ventricular resection was associated with a better LVEF and LVEDD and higher survival and non-recurrence rates than PCI or drug treatment.
Different surgical techniques, each with its own advantages and disadvantages, have been used to reverse adverse left ventricular remodeling due to postinfarction left ventricular aneurysm. The most appropriate surgical technique depends on the location and size of the aneurysm and the scarred tissue, the patient’s preoperative characteristics, and surgeon preference. This review covers the reconstructive surgical techniques for postinfarction left ventricular aneurysm.
We present a case of posterior left ventricular pseudoaneurysm, a rare but potentially lethal complication of inferior acute myocardial infarction. The clinical findings and the customary, noninvasive diagnostic methods used are illustrated. Particularly, the most evident display obtained by the employment of three-dimensional echocardiography in comparison to those supplied by two-dimensional ultrasonic method was illustrated.
Left ventricular outpouchings commonly include aneurysm, pseudoaneurysm, and diverticulum and are now being increasingly detected on imaging. Distinction between these entities is of prime importance to guide proper management as outcomes for these entities differ substantially. Chest radiograph is usually nonspecific in their diagnosis. Echocardiography, multi-detector computed tomography evaluation and angiography are helpful in the diagnosis with their inherit limitations. Cardiac magnetic resonance imaging (MRI) is emerging as a very useful tool that allows simultaneous anatomical and functional evaluation along with tissue characterization, which has diagnostic, theraputic and prognostic implications. This article gives an overview of left ventricular outpouchings with special emphasis on their differentiation using cardiac MRI.
We report the case of a patient with an extensive anterior myocardial infarction complicated by left ventricular systolic dysfunction, left ventricular apical thrombus and an apical left ventricular aneurysm following failed thrombolysis. We obtained serial two-dimensional echocardiograms at short intervals in the acute phase and also during the months of recovery and follow up. The patient was successfully and exclusively medically managed. © the author(s), publisher and licensee Libertas Academica Ltd.
Objective:
The present analysis of the Surgical Treatment for Ischemic Heart Failure randomized trial data examined the left ventricular volumes at baseline and 4 months after surgery to determine whether any magnitude of postoperative reduction in end-systolic volume affected survival after coronary artery bypass grafting alone compared with bypass grafting plus surgical ventricular reconstruction.
Methods:
Of the 1000 patients randomized, 555 underwent an operation and had a paired imaging assessment with the same modality at baseline and 4 months postoperatively. Of the remaining 455 patients, 424 either died before the 4-month study or did not have paired imaging tests and were excluded, and 21 were not considered because they had died before surgery or did not receive surgery.
Results:
Surgical ventricular reconstruction resulted in improved survival compared with coronary artery bypass grafting alone when the postoperative end-systolic volume index was 70 mL/m(2) or less. However, the opposite was true for patients achieving a postoperative volume index greater than 70 mL/m(2). A reduction in the end-systolic volume index of 30% or more compared with baseline was an infrequent event in both treatment groups and did not produce a statistically significant survival benefit with ventricular reconstruction.
Conclusions:
In patients undergoing coronary artery bypass grafting plus surgical ventricular reconstruction, a survival benefit was realized compared with bypass alone, with the achievement of a postoperative end-systolic volume index of 70 mL/m(2) or less. Extensive ventricular remodeling at baseline might limit the ability of ventricular reconstruction to achieve a sufficient reduction in volume and clinical benefit.
Acute myocardial infarction (AMI) can result in ischemic, mechanical, arrhythmic, embolic, or inflammatory complications. The development of mechanical complications following AMI is associated with a significantly reduced short-term and long-term survival. Since the introduction of primary percutaneous coronary intervention as the principal reperfusion strategy following acute ST-elevation myocardial infarction, the incidence of mechanical complications, including rupture of the left ventricular free wall, papillary muscle, and ventricular septum, has reduced significantly to less than 1%. Despite high operative mortality, the lack of an effective medical alternative makes surgical repair the mainstay of current management for these patients.
In this study, we included 236 patients with ischemic heart failure and ejection fraction (EF) <35% who underwent surgical
treatment. Patients were randomized in two groups. There were 116 patients who underwent coronary artery bypass grafting (CABG)
with surgical ventricular reconstruction (SVR) and 120 patients who underwent CABG alone. The hospital mortality rate was
5.8% after isolated CABG and 3.5% after CABG combined with SVR. All survivors had follow-up investigation from four months
to five years, with a mean follow-up time of 31±13 months. The mean New York Heart Association (NYHA) functional class decreased
from 2.9±0.5 to 2.2±0.7 one year after CABG and from 3.1±0.4 to 2.0±0.6 one year after CABG with SVR. We showed that left
ventricular reconstruction significantly decreased EDV from 237±52 to 176±30 and correspondingly increased EF from 32±6 to
39±9. However, after isolated CABG EF did not increase significantly (32±7 preoperatively and 34±11 postoperatively). One-
and three-year rates were 95% and 78% after SVR with CABG and 83% and 78% after CABG alone. Despite the more aggressive surgical
strategy, left ventricular reconstruction did not increase operative mortality and early results were significantly effective
compared with coronary artery bypass grafting alone.
Left ventricular free wall rupture is a rare complication of acute myocardial infarction and accounts for a significant number of fatalities. Pseudoaneurysm is a variety of left ventricular rupture whereby the pericardium seals the defect, forming the wall of the pseudoaneurysm. The diagnosis is usually confirmed with echocardiography, and emergent surgical repair is required in suspected impending rupture. The present report describes the case of a 58-year-old woman who presented with a myocardial infarction due to distal left anterior descending artery occlusion, complicated by ventricular pseudoaneurysm with impending rupture. The patient had an otherwise normal coronary tree.
To determine the clinical and angiographic factors responsible for left ventricular aneurysm formation and the prognosis of patients with aneurysm, 79 patients with a first acute transmural anterior myocardial infarction and angiographically documented isolated left anterior descending artery disease were retrospectively evaluated. Presence of large infarct size and left ventricular volumes, reduced left ventricular function, and evidence of clinical functional impairment were more common in patients with aneurysm (n = 31) than in those without (n = 48). Patients with aneurysm often had total occlusion of the proximal left anterior descending artery without collateral vessels on angiography. During a mean follow-up of 53 months, 10 patients with and three without aneurysm died (P less than 0.01). Compared to survivors with or without aneurysm, the nonsurvivors were older, had significantly larger infarct size and left ventricular volumes and poor systolic function. The incidence of total occlusion of the left anterior descending artery without collaterals was higher in nonsurvivors. In patients with aneurysm, stepwise multivariate analysis revealed that left ventricular ejection fraction and the status of left anterior descending artery obstruction and collaterals were independent predictors of mortality. The study indicates that in patients with a first acute transmural anterior myocardial infarction and isolated anterior descending artery disease, left ventricular aneurysm often results from a large infarct caused by total occlusion of the proximal left anterior descending artery without collateral supply to the infarct region. The reduced survival rate for patients with aneurysm is primarily related to severe global left ventricular dysfunction which may be determined by assessing the residual flow to the infarct region.
To determine factors involved in left ventricular aneurysm formation after transmural anterior myocardial infarction, 79 patients with a first myocardial infarction who underwent cardiac catheterization within 6 months of infarction were evaluated. Patients who had received thrombolytic therapy were excluded. Patients were divided into four groups depending on the status of the left anterior descending artery and the presence or absence of a left ventricular aneurysm: Group I (n = 25): aneurysm with occluded left anterior descending artery; Group II (n = 27): no aneurysm and occluded left anterior descending artery; Group III (n = 23): no aneurysm and patent left anterior descending artery; and Group IV (n = 4): aneurysm with patent left anterior descending artery. Single vessel disease was more common in Group I (aneurysm) compared with Groups II and III (no aneurysm) (chi 2(4) = 12.8; probability value equal to 0.012). Collateral blood supply in the presence of an occluded left anterior descending artery was significantly less in Group I (aneurysm) compared with Group II (no aneurysm) (0.9 versus 2.4, p less than 0.001). The extent of coronary artery disease and collateral blood supply in Groups I and II were directly related (p = 0.012). Neither age, sex nor risk factors for coronary disease correlated with aneurysm formation. At a mean follow-up of 48 months, no differences were observed in the incidence of recurrent angina, new myocardial infarction, embolic events or sudden death. More patients in Group II underwent coronary artery bypass surgery. Total occlusion of the left anterior descending artery in association with inherent poor collateral blood supply is a significant determinant of aneurysm formation after anterior myocardial infarction. Multivessel disease with either good collateral circulation or a patent left anterior descending artery is uncommonly associated with the development of left ventricular aneurysm.
The aim of this study was to establish the effects of postinfarction total or subtotal coronary occlusion on left ventricular remodeling in patients with noninsulin-dependent diabetes (NIDD) compared with the effects in postinfarct nondiabetic patients. The authors selected 100 patients submitted to coronary angiography between 1 and 5 weeks after acute myocardial infarction (T0: 20.5+/-15.4 days) and classified into three groups: G1: NIDD with coronary occlusion/subocclusion (n=24), G2: controls with coronary occlusion/subocclusion (n=43), G3: controls without coronary occlusion/subocclusion (n=33). At time zero (T0) the following parameters were evaluated: end-systolic and end-diastolic volume indexes (ESVi, EDVi), ejection fraction (EF), echocardiographic wall motion score index (WMI), presence of left ventricular aneurysm, and triple-vessel coronary disease. The frequencies of major cardiovascular events were recorded during follow-up. Significantly greater ESVi and EDVi were noted in G2 compared with G3 (P<0.0001), while no significant differences were observed between NIDD patients and controls. Although left ventricular global and segmental dysfunctions were increased in diabetics, controls with coronary occlusion/subocclusion presented more pronounced EF reduction (P<0.0001 G2 vs G3) and higher elevation in WMI (P<0.005 G2 vs G3). Cardiac events during follow-up were elevated in G1 and G2, particularly as regards the occurrence of congestive heart failure. The authors conclude that NIDD seems to influence in a positive way left ventricular remodeling associated with postinfarct total or subtotal coronary occlusion.
The aim of the study was to identify predictors for survival after repair of postinfarction left ventricular aneurysm.
We retrospectively reviewed the records of 149 patients who had an operation for postinfarction left ventricular aneurysm between 1989 and 2001. The following variables were recorded: preoperative clinical, angiographic, and echocardiographic findings and operative procedures. Outcomes were early mortality (<30 days) and long-term survival. Risk factors were pinpointed using t test or Mann-Whitney test, contingency tables, and survival curves. Independent risk factors were identified by logistic regression and Cox regression methods. Mean follow-up was 5.8 years (range, 0 to 13.8 years).
The early mortality (<30 days) rate was 8.7% altogether, and the 5-year cumulative survival rate was 77%. Advanced age, history of ventricular arrhythmia, three-vessel disease, and linear repair technique were independent risk factors for early and total mortality. Poor left ventricular function predicted reduced long-term survival but did not increase surgical risk. Survival was not affected by gender, diabetes, type and severity of symptoms, anterior or posterior aneurysm, revascularization of the left anterior descending artery, or number of distal anastomoses.
Postinfarction left ventricular aneurysm can be repaired with acceptable surgical risk and long-term survival. Survival is reduced in cases with advanced age, history of ventricular arrhythmia, three-vessel disease, poor left ventricular function, and linear repair of the aneurysm.
Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques
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