Interact CardioVasc Thorac Surg 2008;7:256-261. doi:10.1510/icvts.2007.160093
© 2008 European Association of Cardio-Thoracic Surgery
ESCVS article - Cardiac general |
Surgical treatment of postinfarction anterior left ventricular aneurysms: linear vs. patch plasty repair
Mirdavron Mukaddirova,
Jean-Marc Frapierb,*,
Rolland Georges Demariab and
Bernard Albatb
a V. Vakhidov Research Centre of Surgery, Tashkent, Uzbekistan
b Department of Thoracic and Cardiovascular Surgery, CHU Arnaud de Villeneuve Hospital, 371, avenue du Doyen G. Giraud, 34295 Montpellier Cedex, France
Received 15 June 2007;
received in revised form 14 November 2007;
accepted 19 November 2007
 Presented at the 56th International Congress of the European Society for Cardiovascular Surgery, Venice, Italy, May 17–20, 2007.
*Corresponding author. Tel.: +33-4-67-33-62-72; fax: +33-4-67-33-62-75.
E-mail address: jm-frapier{at}chu-montpellier.fr (J.-M. Frapier).
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Abstract
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Background: The patch plasty repair is increasingly advocated over linear closure in the surgical treatment of postinfarction anterior left ventricular aneurysm (LVA). A comparative estimate of the clinical results of these two techniques seemed in order. Methods: Between 1985 and 2004, 53 patients (mean age of 64.2±8.3 years) underwent repair of anterior LVA. Twenty-seven patients underwent linear repair (group 1) and 26 patients patch plasty (group 2). The mean left ventricular ejection fraction was 33.9±8.2% in group 1 vs. 29.7±10.2% in group 2 (P=0.118). Preoperatively 85.2% of patients in group 1 were in NYHA functional class III or IV vs. 88.5% in group 2 (P=0.71). All patients had preoperative recurrent ventricular tachycardia (VT) and non-guided encircling cryoablation for treatment of VT was performed in all patients. Coronary revascularization was performed in 29.6% of patients in group 1 and 42.3% in group 2 (P=0.398). Results: The overall in-hospital mortality was 1.9% as one patient died of low cardiac output (LCO). LCO was the most frequent early postoperative complication and was observed in 66.7% of patients in group 1 vs. 65.4% in group 2 (P=1.000). LCO was related to right coronary artery disease on multivariate analysis (odds ratio 6.9, P=0.0097). Mean follow-up was 6.4±4.8 years (range 1 day–17.5 years). Overall survival at 10 years was 65.5% of patients in group 1 vs. 60.6% in group 2 (P=0.395). At 10 years, 91.5% of patients were free from VT or sudden death in group 1 vs. 81% in group 2 (P=0.269). At follow-up the patients' functional status improved and among survivors 76.9% in group 1 were in NYHA functional class I–II vs. 62.5% in group 2 (P=0.432). Deaths from congestive heart failure (CHF) occurred in 38.5% of patients in group 1 vs. 55.6% in group 2 (P=0.632). On multivariate analysis a preoperative left ventricular end-diastolic pressure above 20 mmHg was a predictor of mortality from CHF (odds ratio 9.6, P=0.038). Conclusions: Our study did not reveal significant differences between linear closure and patch plasty repair in the short- and long-term. The choice of repair technique should be adapted to each patient's anatomical and physiological characteristics.
Key Words: Postinfarction; Left ventricular aneurysm; Linear repair; Patch plasty; Ventricular tachycardia; Cryoablation
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1. Introduction
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In 1958, Cooley and colleagues performed the first postinfarction aneurysm resection and linear repair of left ventriculotomy with the use of cardiopulmonary bypass (CPB) [1]. Until 1980 the linear closure technique was the standard in heart aneurysm surgery. The technique offered by Levinsky and colleagues [2] in 1979 supposed the performance of left ventricular reconstruction with a woven Dacron patch after resection of anterior postinfarction aneurysm. The technique was improvised after an unsuccessful linear repair and became the principal new technical solution. In 1985, Jatene and Dor independently presented a fundamentally new, anatomic left ventricular reconstruction method with endoventricular circular reduction and stitching patch in the formed ventriculotomy orifice [3, 4]. This method, the so-called patch plasty repair has gained adherents and is now increasingly advocated over linear closure for the surgical treatment of postinfarction anterior left ventricular aneurysm (LVA). Since these two methods claim as their same goal an improvement of ventricular failure by elimination of dyskinetic areas and ventricular volume reduction, we conducted a comparative estimate of their clinical outcomes in our unit.
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2. Patient population and methods
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Between 1985 and 2004, 53 patients underwent repair of postinfarction anterior LVA. Preoperatively all patients had recurrent ventricular tachycardia (VT). There were 43 (81.1%) men and ten women. The mean age was 64.2±8.3 years. Twenty-seven patients who underwent linear repair (group 1) were compared to 26 patients who had patch plasty (group 2). There was no significant difference between the two groups across a wide spectrum of preoperative characteristics (Table 1). The preoperative study included a 24-h ambulatory electrocardiography, echocardiogram, coronary angiogram, left ventriculogram, and electrophysiologic studies (EPS). The EPS protocol has been described previously [5]. Postoperative EPS was performed in all patients before discharge.
On coronary angiography, 25 patients (47.2%) had single-vessel disease, 12 (22.6%) had two-vessel disease, and 12 patients (22.6%) had three-vessel disease. Coronary artery lesions were absent in four patients (7.6%). Occlusion and critical stenosis of the left anterior descending artery (LAD) occurred in 49 patients (92.5%). We did not identify a statistically significant difference between the two groups in number and localization of lesions in the three major coronary arteries (Table 1). The mean left ventricle (LV) ejection fraction was 31.7±9.4% (33.9±8.2% in group 1 and 29.7±10.2% in group 2, P=0.118). Preoperatively 46 patients (86.8%) were in NYHA functional class III or IV (85.2% in group 1 and 88.5% in group 2, P=0.710).
2.1. Surgical technique
The operative protocol has been described previously [5]. Briefly, under cardiopulmonary bypass, moderate hypothermia (mean temperature 28.2±3.3 °C), and cold blood or crystalloid cardioplegia, anterior left ventriculotomy was performed over the aneurysm. Thrombus if present was evacuated and non-guided encircling cryoablation for treatment of VT was performed in all patients. Concomitant coronary artery bypass grafting (CABG) was performed in 19 (35.8%) patients (29.6% in group 1 and 42.3% in group 2, P=0.398). The aorta was unclamped just before left ventricle repair.
For linear repair, the resection left about 1 cm of the scarred fibrous tissue in order to facilitate the left ventricular wall suture. This suture was made by double-row (using 2-0 monofilament polypropylene suture): the first row of wide U-shaped horizontal stitches on two continuous Teflon strips, the second continuous blanket row, where the needle was stuck into and pricked out on the strip. In order to prevent the suture from cutting through and to control the possible bleeding one could strengthen the suture zone with a third strip under the second row of stitches.
For patch plasty ventriculotomy closure, the endoventricular circular suture using continuous 2-0 monofilament polypropylene was placed at about 1 cm above the border zone. This was done in order to prevent alteration of normal myocardium and allows the normal shape of the left ventricle to recover. The Dacron patch was stitched in the ventriculotomy orifice area with single U-shaped stitches reinforced by Teflon pledgets. The excluded fibrous zone was trimmed and sutured over the patch in an overlapping way in order to improve haemostasis and to avoid formation of a new cavity. CPB was then discontinued after proximal anastomosis of saphenous graft if needed and after haemodynamic stability had been reached.
The mean duration of cardiopulmonary bypass (CPB) was 117.2±53.3 min (90.5±33.9 min in group 1 vs. 143.9±56.2 in group 2, P<0.0001), and the average duration of aortic cross-clamping was 41.3±21.6 min (30.3±19.9 min in group 1 vs. 48.7±19.9 in group 2, P=0.01) (Table 2).
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3. Statistical analysis
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Statistical analysis was performed using the SAS statistical software (SAS Institute, Inc., Cary, NC) at the Medical Department of Statistics. Pre- and perioperative data were collected through review of the patients' hospital records. Follow-up was completed by telephone interviews with patients, family members and cardiologists. Rates of survival, freedom from VT or sudden death were estimated by the Kaplan–Meier, and curves were compared by log-rank test. Multivariate regression analysis was used to determine the potential risk factors of early postoperative low cardiac output (LCO) syndrome and deaths from congestive heart failure (CHF). The results were expressed as mean value±S.D. A P-value of 0.05 or less was considered statistically significant.
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4. Results
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4.1. Mortality
The overall in-hospital mortality was 1.9% as one patient of group 2 died of LCO. There was no statistically significant difference in early mortality between the two groups (Table 3). Mean follow-up was 6.4±4.8 years (range 1 day–17.5 years). Overall survival at 1, 5 and 10 years was 88.4, 73.3 and 61.7%, including early mortality (92.3, 79.7, 65.5% in group 1 vs. 84.1, 67.3, 60.6% in group 2, respectively, P=0.395) (Fig. 1). Two patients died suddenly (one in group 1 vs. one in group 2, P=1.000) and three patients died of myocardial infarction (two in group 1 vs. one in group 2, P=0.6). The main cause of late death was worsening CHF in 10 (45.5%) patients (38.5% in group 1 vs. 55.6% in group 2, P=0.632), including two patients who underwent successful cardiac transplantation and were censored as dead in the actuarial survival study. Risk factors for death from CHF after aneurysmectomy on univariate analysis were (Table 4) right coronary artery disease (P=0.039) and left ventricular end-diastolic pressure (LVEDP) above 20 mmHg (P=0.027). On multivariate analysis, only preoperative LVEDP >20 mmHg significantly increased the risk of mortality from CHF (Table 5).
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Fig. 1. Survival for patients with linear repair (dotted line) or patch plasty (continuous line); P=0.395 (NS).
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Table 4 Univariate analysis for postoperative low cardiac output syndrome and deaths from congestive heart failure
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Table 5 Multivariate analysis for postoperative low cardiac output syndrome and deaths from congestive heart failure
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4.2. Rhythm
The immediate antiarrhythmic success rate based on postoperative EPS was 94.3% (96.3% in group 1 vs. 92.2% in group 2, P=0.61). At 10 years, 86.4% of patients were free from VT or sudden death (91.5% in group 1 vs. 81% in group 2, P=0.269) (Fig. 2). Permanent pacemakers were implanted for complete atrioventricular block in 3 (5.7%) patients (1 case in group 1 vs. 2 cases in group 2, P=0.61). Implantation of cardioverter defibrillators for induced or spontaneous recurrent ventricular tachycardias was performed in 5 (9.4%) patients (2 cases in group 1 vs. 3 cases in group 2, P=0.351).
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Fig. 2. Survival free from ventricular tachycardia or sudden death for patients with linear repair (dotted line) or patch plasty (continuous line); P=0.269 (NS).
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4.3. Functional status
During follow-up, the patients' functional status improved in both groups. Among 29 interviewed long-term survivors, 20 (69%) were in NYHA functional class I–II and there was no significant difference between the two groups (76.9% in group 1 vs. 62.5% in group 2, P=0.784).
4.4. Morbidity
LCO syndrome was the most frequent early postoperative complication and observed (Table 3) in 35 (66%) patients (in 66.7% in group 1 vs. 65.4% in group 2, P=1.000). Single risk factor for early postoperative LCO on univariate analysis was coronary revascularization (P=0.037); of 19 patients who received CABG, LCO developed in 16 (Table 4). On multivariate analysis, LCO was related to right coronary artery disease (Table 5).
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5. Discussion
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5.1. Mortality
In our study the postoperative mortality consisted of 1.9% and 10-year survival was 61.7% with no significant difference between the two groups. These results are comparable with other studies, where hospital mortality varies within the limit of 3.7–9.8% and 10-year survival from 55.7 to 60.4% [6–8]. These studies were not able to reveal any significant difference in early and late outcomes for patients treated with linear repair or patch plasty. One of the main causes of early mortality after aneurysmectomy is severe LCO. LCO is the most frequent postoperative complication occurring in 21–37% of cases, without significant difference between the two techniques [9–12]. The frequency of temporary hemodynamic support with intra-aortic balloons varies within the 1.8–13.9% range [8, 9, 11, 13, 14]. LCO is the cause of 44.4–87.5% of operative and hospital mortality after aneurysmectomy [10, 14, 15]. In our study LCO was identified in 35 patients (66%) who required inotropic support and implantation of an intra-aortic balloon was required in 6 (11.3%) cases. Type of LV repair did not influence the frequency of LCO syndrome development. On multivariate analysis right coronary artery disease was the only significant predictor of early postoperative LCO. This has been previously demonstrated by Pasini and colleagues [16]. One can easily understand that inferior wall impairment in a patient with large anterior necrosis could be a strong adverse factor. Clearly, determining the viability of left ventricular lateral and inferior wall before anterior LVA surgery on these patients is of the utmost importance. Regarding late postoperative mortality, congestive heart failure was the main cause of death in both groups. Preoperatively, most of those patients had severe left ventricular dysfunction as assessed by univariate and multivariate analyses, revealing that preoperative LVEDP above 20 mmHg significantly increased the risk of mortality from CHF. This parameter has been previously underlined by Vural and colleagues [10] who found that a LVEDP >20 mmHg was one of the most important predictors of postoperative LCO and lower survival rates. For those patients, heart transplantation remains today the only solution in case of worsening CHF, though a combination of surgical repair and cell transplantation could emerge as a solution for late postoperative CHF. In this regard, the experimental study of Matsubayashi and colleagues, who used bioengineered vascular smooth muscle grafts for LV aneurysm repair [17], is of special interest.
5.2. Coronary revascularization
CABG is one of the important components of LVA surgery, and the revascularization rate varies in the literature from 68 to 100% [6, 8, 9]. Despite a lack of significant results favoring long-term survival improvement by coronary revascularization, the vast majority of authors agree on the necessity of concomitant CABG, particularly in patients with multivessel disease [8, 10, 11, 13, 18, 19]. For Vural and colleagues, although CABG did not affect functional status or long-term mortality, postoperative low cardiac output incidence was significantly reduced when coronary revascularization was added to aneurysm repair [10]. This is in strong contradiction with our finding that coronary revascularization was related to early postoperative LCO syndrome. In our study, concomitant CABG was performed in 35.8% of cases and the average number of bypasses was 1.3 grafts per patient. As this revascularization rate is less than other previously mentioned studies, our postoperative and late mortality rates compare favorably with these reports [8, 11, 13]. Therefore, we cannot state that coronary revascularization is the sole factor in improving the patients' survival. However, the small size of both groups and the lack of preoperative viability studies could preclude further analysis.
5.3. Rhythm
The isolated aneurysmectomy is accompanied by a high frequency of VT recurrence with high incidence of sudden death in various periods after surgery [15, 20]. Baufreton and colleagues showed a 29.6% rate of mortality within the first 30 postoperative days caused by intractable VT [15]. Bechtel and colleagues reported that surgical treatment of 147 patients who underwent anterior LVA resection without concomitant anti-arrhythmic procedures led to sudden arrhythmic death in 36.8% of total mortality during the 5-year follow-up [20]. In our study, sudden death was absent during early postoperative period and comprised only 10% (2 cases) of late mortality during the 10-year follow-up. Reconstruction technique, linear vs. patch closure, did not influence these results. In our opinion this positive result is the direct consequence of systematic application of cryoablation for the treatment of recurrent VT. The patients with preoperative VT (spontaneous and induced) should undergo concomitant anti-arrhythmic procedure. Many authors have reported similarly satisfactory results of anti-arrhythmic surgery in patients with postinfarction LVA [21–23]. Implantation of a cardioverter-defibrillator is a palliative procedure. LVA surgery with concomitant antiarrhythmic procedure is the only curative solution able to address in one intervention the three components of this entity, namely, cardiac insufficiency, ischemic disease and arrhythmias.
5.4. Repair technique
The choice of repair technique is the crux of LVA surgery. Different approaches to choosing the type of repair are found in the studies devoted to comparative estimation of the two principal methods. Tavakoli and colleagues [18] proceeded from the assumption that linear closure is preferable for aneurysms with high left ventricular volume. For patients with extensive septal fibrous scar or with involvement of the subvalvular mitral apparatus, authors consider the usage of the patch-technique as the correct one. This approach is closely related to the work of Vural and colleagues [10], where the circular patch plasty is performed in the case of an extensive and definite fibrotic aneurysmal sac with a well-formed neck. Linear closure or small plication is preferable in a small wide-based aneurysm, vaguely separated from the surrounding viable myocardium. However, neither study identified essential difference between two reparative methods relative to hospital mortality and survival in the long-term follow-up. Patch plasty should be used for patients with sharply decreased left ventricular function, in accordance with the point of view of Dor and colleagues [21], especially in the case of large akinetic area [24]. Eventually, linear closure should be limited to small ventricular aneurysms and large ventricular aneurysms extending into the septum should be treated by patch plasty [25]. In our study, patch plasty was introduced in 1992, when the choice of LVA repair technique was based mainly on aneurysm size, as in the paper of Doss and colleagues [25], even if, eventually, surgeon's preference was the last criterion. Moreover, patch plasty was elected if linear repair would have led to a major risk of forming of small-volume left ventricle or in the presence of calcified aneurysm.
Therefore, because one technique was not shown to be better than the other, the choice of technique for repair of postinfarction LVA should be adapted to each patient's anatomico-physiological characteristics. This attitude is shared by most authors whose studies are dedicated to the comparative analysis of linear and patch repair techniques of LVA [7, 9, 18, 25].
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6. Study lmitations
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This study was retrospective and encompassed a small number of patients. Data regarding ventricular diameters and ventricular volumes were not available for the entire cohort and could not be included in the statistical analysis. Linear repair prevailed in the initial period, while the application of patch plasty in these series started from 1992. In this regard, linear repair group had a longer follow-up compared with patch plasty group and this limitation could have influenced the late clinical results.
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7. Conclusion
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If surgical ventricular reconstruction is one of the treatment strategies in anterior LVA, our study did not reveal a significant difference between two repair techniques in short- and long-term results. The choice of repair technique for postinfarction LVA should be adapted to each patient's anatomico-physiological characteristics. Concomitant cryoablation for the treatment of recurrent VT substantially reduces VT recidivity and sudden death after aneurysmectomy, independently of the type of repair.
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Acknowledgements
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We thank Defez Christine, MD and Barbotte Eric, MD, Medical Statistics Department, Arnaud de Villeneuve Hospital Montpellier, for help with the statistical analysis. We greatly thank Kinet Maxime for his helpful assistance in revising the final manuscript.
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Abstract
1. Introduction
