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