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SYMPOSIUM ON LEFT VENTRICULAR VOLUME REDUCTION, PART I
Left Ventricular Aneurysmectomy: Endoventricular Circular Patch Plasty or Septoexclusion Antonio Maria Calafiore, M.D., Sabina Gallina, M.D., Michele Di Mauro, M.D., Marco Pano, M.D., Giovanni Teodori, M.D., Gabriele Di Giammarco, M.D., Marco Contini, M.D., Angela L Iaco, ` M.D., and Giuseppe Vitolla, M.D. Department of Cardiology and Cardiac Surgery, University “G. D’Annunzio,” Chieti, Italy ABSTRACT Background: Septoexclusion is a technique described by Guilmet in the mid 1980s. Its indications and midterm results are evaluated and compared to those obtained with the Dor operation. Methods: From January 1998 to April 2001, 79 patients had an exclusion of scars following myocardial infarction in left anterior descending artery (LAD) territory. Fifty of them (63.3%) had the Dor operation (Group D) and 29 (36.7%) the Guilmet operation (Group G). Dor technique was used when the involvement of the septum and the free wall was roughly similar. Guilmet technique was indicated when the septum was involved at a greater extent than the free wall. Ejection fraction (EF) was lower and end-diastolic volumes were higher in Group G. Incidence of functional mitral regurgitation was similar in both groups. Results: Thirty-day mortality was 7.6% (8.0% in Group D versus 6.9% in Group G, p = ns). After a mean of 21.0 ± 8.5 months, five patients (6.9%) died, two in Group D and three in Group G. Causes of death were cardiac related in four and not cardiac related in one. Mean follow-up of the 68 survivors was 24.3 ± 12.0 months (range: 4-38 months). Fifty patients (73.5% of the survivors) improved (28 in Group D and 22 in Group G, p = 0.026), whereas in 18, New York Heart Association (NYHA) class remained unchanged or worsened. Both groups showed an increase of EF and a volumetric reduction, whereas stroke volume remained unchanged. Fewer patients had mitral regurgitation than in the preoperative period (41.3% versus 65.8%, p = 0.013) and at a lesser extent (1.7 ± 0.7versus 0.7 ± 0.6, p < 0.001). Conclusions: Our results show that both Dor and Guilmet techniques are effective in the surgical treatment of left ventricular dyskinetic or akinetic areas related to LAD territory. Each technique has its own indications and has to be addressed to patients with different extension of septal scars. (J Card Surg 2003;18:93-100) Surgical treatment of left ventricular (LV) aneurysms started, in the recent era, with Likoff and Bailey, who, in 1955, placed a large clamp Address for correspondence: Antonio Maria Calafiore, M.D., “G. D’Annunzio” University, Division of Cardiac Surgery, S. Camillo de’ Lellis Hospital, via C. Forlanini, 50, 66100 Chieti, Italy. Fax: 39 0871 402239; e-mail:
[email protected]
on a huge aneurysm that was resected and sutured.1 Later on, Cooley and colleagues described a simple technique of lateral resection and direct closure2 that remained the usual way to correct any LV aneurysm up to the mid-1980s, when, independently, Jatene3 and Dor et al.4 reported two techniques that allowed a more anatomical
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CALAFIORE, ET AL. LEFT VENTRICULAR ANEURYSMECTOMY
reconstruction of LV shape for dyskinetic or akinetic areas following myocardial infarction in the left anterior descending (LAD) artery. In the same period another French surgeon, Guilmet, and his colleagues described a surgical technique that had its specific indication in large aneurysms where the septum was mainly involved.5 This technique remained obsolete for years and has been used in our institution since 1998 with selected indications. In this report our experience with Guilmet technique is evaluated, to compare its indication and midterm results with the Dor technique, the most used method of LV Aneurysmectomy.
J CARD SURG 2003;18:93-100
TABLE 1 Preoperative Data
Age (y, mean) ≥75 y Female gender NYHA class Dyspnea Angina and dyspnea Ventricular arrhythmias Diabetes Single LAD disease
Group D n = 50
Group G n = 29
p
64.7 ± 9.3 6 (12.0%) 12 (24.0%) 2.7 ± 0.7 22 (44.0%) 28 (56.0%) 3 (6.0%) 13 (26.0%) 5 (10.0%)
63.0 ± 9.6 4 (13.8%) 6 (14.8%) 2.9 ± 0.7 14 (48.3%) 15 (51.7%) 7 (24.1%) 6 (20.7%) 7 (24.1%)
ns ns ns ns ns ns 0.047 ns ns
y = years; NYHA = New York Heart Association; LAD = left anterior descending.
MATERIAL AND METHODS Patient selection From January 1998 to April 2001 79 patients had an exclusion of scars following myocardial infarction in LAD territory, both in dyskinetic (44) or akinetic (35) phase. Fifty of them (63.3%) had the Dor operation (Group D), and 29 (36.7%) the Guilmet operation (Group G). All of the patients had a normal or moderately impaired right ventricular function and a mean pulmonary pressure not higher than 40 mmHg without severe hepatic failure. Mean age was 60.1 ± 9.5 years; there were 10 females (12.7%) and 19 diabetic patients (24%). All of the patients had dyspnea, and 43 also had angina. Mean New York Heart Association (NYHA) class was 2.8 ± 0.7; 49 patients (59.9%) were in NYHA Class III or IV. Ten patients (12.7%) had a history of ventricular arrhythmias. Incidence of preoperative ventricular arrythmias was higher in Group G related to a more important septal involvement in these patients. Preoperative echocardiograms showed a mean ejection fraction and an enddiastolic volume index of 34 ± 10% and 129 ± 44 mL/m2 , respectively. Fifty-two had mitral regurgitation with a mean value of 1.7 ± 0.7. Differences between the two groups are shown in the Tables 1 and 2. Preoperative angiography showed that 12 patients had 1-vessel disease, 29 had 2-vessel disease, and 38 had 3-vessel disease; 3 had left main disease. Left ventriculography showed a mean percentage of asynergy of 54 ± 9% (50 ± 13% in Group D and 60 ± 13% in Group G, p = 0.001). Mean angiographic ejection fraction was 31 ± 11% (34 ± 10% in Group D and 29 ± 12.0% in Group G, p = 0.05).
TABLE 2 Preoperative Echocardiographic Data
EF (%) ≤35% EDv (mL/m2 ) ESv (mL/m2 ) SV (mL/m2 ) Patients with MR MR degree (1-4/4) Dyskinetic/akinetic areas
Group D n = 50
Group G n = 29
p
37 ± 10 15 (30.0%) 115 ± 33 89 ± 34 27 ± 12 32 1.7 ± 0.7 27/23
30 ± 11 22 (75.9%) 152 ± 63 109 ± 56 40 ± 23 20 1.8 ± 0.5 17/12
0.005
