Download - Left ventricular aneurysm
Dr R.C Barik/Dr A N PatnaikNIMS, Hyderabad
LEFT VENTRICULAR ANEURYSM REPAIR
TIMELINE FACTS COMMENTS
1757
1881
1912
1944
1951
1955
1958
LV ANEURYSM by autopsy
LVA+ CAD
Congenital LVA Rx-surgical ligation
Fasciae latae plication.
First LV ANGIOGRAM
LVA repair without CPB
Cooley et al successfully performed a linear repair of a LVA using CPB.
Geometric ventricular techniques
John Hunter
Weitland
Beck
Likoff and Bailey
Stoney et al, Daggett et al,
Dor et al, Jatene, and Cooley et al.
NATURAL HISTORY OF CAD
In MI with LV-Aneurysm-20% survivors develop symptomatic HF in 5 years and 50% die in 1 st 1-2 yr even with advance HF Rx.(NHLBI)
Aim 1.The intervention timing-symptom/aneurysm size/CAD
2.Define the aneurysm-ECHO/LV ANGIOGRAM/CMRI.3.Surgical ventricular reduction
MR.X
age: 78 year / M
DM II,HTN,CKD-10 yrs
CAD S/P PTCA PROX RCA AND DISTAL LAD - 7 yrs
back.
PAD-RT great toe amputation-7 yr back .
Old CVA-lacunar infarct improved-7 yr back .
STEMI (AWMI)-S/P-STK+, PTCA- PROX LAD / DISTAL
RCA-and discharged -10/2012
PATIENT PROFILE
CAG-11/10-2012
PRIMARY PTCA TO PROX LAD -10/2012
CAG-10/2012
RCA STENTING-10/2012
Readmitted with gross Heart Failure,
NYHA-IV
2 syncopal attacks .
NO ANGINA
LV-apical aneurysm with clot
10/12/2012
ON EXAMNINATION
BMI-24KG/M²
Raised JVP and B/L mild pedal edema
PR-86/min ,BP- 130/90 mmHg.
Dyskinetic apex, no murmur
PVD+(amputed- right great toe ).
No neurological deficit
Other systems normal.
PREOP EVALUATION
PROFILE OBSERVATION
ROUTINE LAB HB,-9.2GM%,FBS-154,Urea-24,Cr-1.7GM%,RBS-227.normal
electrolytes
ECG Q wave in V1-V5,ST-Elevation in V2,3,4
X-Ray Chest- Cardiomegaly-protruded left heart border .
2D ECHO- RWMA-in LAD territory , Large Apical Aneurysm ,Severe LV-
Dysfunction ,EF- 30 %, Gr-1 Diastolic Dysfunction .no MR/VSD.
INVESTIGATION
PRE OP ECG-EXTENSIVE AWMI
LV ANEURYSM
CORONARY ANGIOGRAM-( F-4122 / 11-12-2012) LAD- Proximal & Mid Stent Patent ,Total occlusion in distal LAD after
the 2nd STENT
LCX- Non dominent . Near total occlusion
OM1- Diffusly Disseased .
RCA- Dominant , both Stent patent in Proximal and distal RCA
PDA- Diffusly Disseased.
LV-Angio- Mod LV-Dysfunction , Large apical aneurysm +.
B/L-Renal artery – 30% Stenosis in Both Renal arteries .
B/L LL Arteries- Diffusly disseased with multiple stenosis in
femoral artery .
LCX-SUBTOTAL AND GOOD SIZE OM1-11/12/2012
LAD-2 DES AND DISTAL ISR 100% 12/2012
RCA-PROX AND DISTAL DES PATENT-12/2012
LV ANGIO IN RAO 30º-12/2012
ANEURYSM OF EVENING
CARDIAC MRI-20/12/2012
LV
EDD=5.5/ ESD=4.1CM
EDV: 127ml/m2, ESV: 84ml /M2(CRITICAL VOL-
120/80ML/M²)
EF: 33% SV: 43ml
CO: 3.1L/m2,
LV Mass: 149gm /m2
TERRITORY BASELINE PEAK STRESS
Basal LVAnterior/Post-septum
Anterior/Post/ALW/PL Wall
MID LV: Anterior/Post septum
Anterior/PW AW/PW
APICAL LV: Anterior Posterior
Septal Lateral Apex:
1 in all segments
2/12/11/1
4444
LEFT VENTRICULAR WALL MOTON ANALYSIS
LV Apical aneurysm 2C area :S=18sqcm, D=15sqcm 4C area S=14sqcm, D=13sqcm Neck>3cm
Delayed Enhancement: No myocardial edema. Basal LV : 0 - 25% subendocardial DCE Mid LV: 25-50% subendocardial DCE in AW
and ant septum.Distal LV and APEX:transmural DCE
: CMRI CONCLUSION
Type III LVA.RWMA in LAD territory Severe LV dysfunction 0-25% subendocardial scar in proximal LAD territory
(viable) 25-50% subendocardial scar in mid LAD territory (partially
viable) Transmural scar in distal LAD territory (non viable) LV Apical aneurysm Significant hibernating myocardium in LAD territory RV : Normal size & function Mild MR/No LV thrombus/No pericardial effusion
ANEURYSM REPAIR+CABG
To be worthy of operation, A dyskinetic or akinetic left ventricular aneurysm should significantly enlarge left ventricular end-systolic volume index (over 80 mL/m2) and end-diastolic volume (over 120 mL/m2)-CRITICAL VOLUME and surgery aims at minimum on table LV volume by mannicune 50 ML/M² Relative indication 1.CHF/arrythmia/embolism/rupture
Aim: correct the size and geometry of the LV, reduce wall tension
and improve pump function, functional status and survival.
CABG X1 graft-SVG to LAD.
Huge Cardiomegaly. Moderate pericardial effusion.
Apex and lateral wall adherent to pericardium.
Large LV apical aneurysm extending to lateral wall, wall thinned
out and fibrosed. Small fresh clot in aneurysm wall.
Papillary muscles, separated widely, few chordae elongated.
LAD- Extending into aneurysm wall, plaques+. LAD involving
stented area thickened.
INTRA OPERATIVE FINDINGS (ON PUMP+CBP)-DATED-----26/12/2012 and
discharged 7/01/2013
True ischemic dilated cardiomyopathy (Type 3)
The mannequin is inflated at 50 ml/m2 and inserted into the ventricle.
Dacron patch
Fontan’s stich
The patch (Dacron) is tailored if neck>3cm
POST OP ECG-JUST EVOLVED ASWMI
Post OP X-RAY ON 7/2/2013
Post OP ECHO
EDV-110ML/M²ESV-60ML/M²
LVEF>45%
07-02-2013
Post Operative fol low up
Now under admission for
Pedal edema due to stasis-SVG to LAD
No CHF
Ef-40%-50%
Sutural line infection(sternal)-now under Rx.
Acute on chronic renal failure-now under Rx
Definit ion of LVA Centerl ine analysis of RWMA on LV angio in 30º RAO shows hypocontracti le segments moving more than 2 standard deviat ions out of normal range.
DISCUSSION
Causes of LVA
Preserved contractility of surrounding myocardium
Transmural infarction
Lack of collateral circulation
Lack of reperfusion
Elevated wall stress
Hypertension
Ventricular dilation
Wall thinning
Coronary Artery Surgery Study (CASS)-
7.6% had angiographic evidence of left ventricular
aneurysms.
95% of true LV aneurysms after MI
False aneurysms of the LV from contained rupture 5 to 10
days after MI and mostly in LCX lesion
LVA occurs within 48 hours-50% and
2 weeks-100% after infarction.
88% of dyskinetic ventricular aneurysms after AWMI.
Linear repair and septoplasties by Cooley .
Repair of anteroseptal ventricular aneurysm by Stoney
capitonnage technique by Cabrol
Overcoat Aneurysmoplasty By Guilmet
LV reconstruction with a Dacron patch by Levinsky
LV reconstruction technique by Jatene.
The endoventricular circular patch plasty (Dor procedure)
Dor’s procedureIn the endoventricular circular patch plasty by Dor, the
procedure is carried out under cardioplegia.
The left ventriculotomy is performed in the akinetic or dyskinetic zone (transaneurysmal ventriculotomy), the thrombus is removed .
An endoventricular circular suture (Fontan maneuver) is placed 1 cm distal to the border of healthy muscle in order to prevent its inclusion and allows recreation of the normal shape of LV using continuous 2-0 monofilament polypropylene suture.
Dor’s procedure
Following this, a balloonis placed in LV cavity and inflated to the theoretical diastolic volume of 50—70 ml/m2, and the circular suture is tightened and tied up.
This maneuver makes the definition of the circular patch size easier, which can consist of autologous (endocardium or pericardium) or synthetic tissue.
The patch size is trimmed to match the circular suture circumference after deflation of the balloon.
The patch is fixed by a continuous 2-0 suture inside the LV cavity on the border labeled by the circular suture.
Post Operative ComplicationsLow cardiac output - 22%–39%Ventricular arrhythmias - 9%–19%Respiratory failure - 4%–11%Bleeding - 4%–7%Dialysis-dependent renal failure - 4%Stroke - 3%–4%
SVR (Surgical ventricular restoration).Reduces LV volumesRestore ell iptical shape Remodell ing (LAPLACE’S LAW).INCREASE EFREDUCES WALL STRESS AND LVEDP.INCREASE STROKE WORK
Based on the following observation
10 YR survival is 90% in asymptomatic and 46% in symptomatic
Survival in medically treated patients with left ventricular aneurysm based on presence (group B) or absence (group A) of symptoms. (Grondin P, et al: Natural history of saccular aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1979; 77:57.)
The diagram shows the strict relationship between spericity index (short/long axis) on the abscissa and ejection fraction (ordinate).
Menicanti L , Di Donato M MMCTS 2005;2005:mmcts.2004.000596
© 2005 European Association for Cardio-thoracic Surgery
Effects of aneurysmectomy on VEDV), ejection fraction (EF), and wall tension. Hemodynamic assessment during exercise after left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1994; 107:178.)
Relationship between stroke work index and left ventricular end-diastolic pressure. Hemodynamic assessment during exercise after left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1994; 107:178.)
Simulated left ventricular aneurysm and aneurysm repair in swine. J Thorac Cardiovasc Surg 1990; 100:745.
Survival in patients with left ventricular aneurysm and three-vessel coronary disease treated with medical or surgical therapy . The inf luence of surgery on the natural history of angiographically documented left ventricular aneurysm: the Coronary Artery Surgery Study. Circulat ion 1986; 74:110.)
Repair of dyskinetic or akinetic left ventricular aneurysm: results obtained with a modif ied l inear closure. J Thorac Cardiovasc Surg 2001; 121:675.
Summary of the results obtained with SVR NON RANDOMISED AND NON COMPARATIVVE
Menicanti L , Di Donato M MMCTS 2005;2005:mmcts.2004.000596
© 2005 European Association for Cardio-thoracic Surgery
BEFORE STICH TRIAL
EHA
.
RESULTS OF STICH trial (Surgical Treatment for Ischemic Heart Failure)are recently published
Surgical Treatment for Ischemic Heart Failure (STICH) tr ial( -VE
TRIAL)
But we are hopeful larger study only clarify Because 1.NEW TECH 2.DEVICES 3.CPB AND ANAES.
ANATOMICAL LV VOLUME REDUCTION HAS NO EFFECT ON KAPLAN-MAYER’S LIFE SURVIVALPROJECTION OVER 5 YRS
TAKE HOME MESSAGEIN ABSENCE OF PRECISE GUIDELINES TO
MANAGE LV-ANEURYSM FOLLOWING AMI ,INDIVIDUALISED SURGICAL APPROACH AFTER CAREFUL CLINICAL AND IMAGING ASSESMENT CAN GIVE GRATIFYING RESULT AS IN THIS CASE .
Thank you