Elective operations for left ventricular asynergy

Abstract

. Elective operations for left ventricular asynergy. Operative results in 45 patients with symptomatic left ventricular asynergy are reviewed. The main symptoms were congestive heart failure in 77-7%, angina in 3141%, arrhythmias in 11-1%, and systemic thromboembolism in 2 2% of the patients.All patients had left heart catheterization, 40 had left ventricular angiography, and 27 had selective coronary arteriography. The last myocardial infarction occurred within three months preoperatively in 15 patients and more than 13 months prior to surgery in 27 patients.The cardiac index was 1-5 l/m2/min or less in six patients and the left ventricular end diastolic (LVED) pressure was 25 mmHg or higher in 15 patients.All patients were operated upon electively with the use of cardiopulmonary bypass. Excision of the left ventricular aneurysm was performed in 39 cases and plication in six.The immediate survival rate was 66 6%. The lowest mortality rate was among patients with angina (12-5%) and the highest in those with association of congestive heart failure and angina (66-6%).The mortality rates among patients with recent or old myocardial infarction were 46-6 and 22-2% respectively.One of the six patients with a cardiac index of 1-5 l/m2/min or less and seven of the 15 patients with LVED pressure of 25 mmHg or higher were discharged from hospital.It is concluded that ventricular aneurysmectomy has to be considered an elective procedure in order to obtain predictable results and that ideal indications for operation are angina or congestive heart failure refractory to medical treatment, associated with acceptable haemodynamics, a cardiac index of 2-0 l/m2/min or higher, and a LVED pressure below 25 mmHg. Beck (1944) was the first to describe a planned operation for a ventricular aneurysm by external reinforcement with pericardium and fascia lata. Likoff and Bailey (1955) reported the use of clamps for a left ventricular aneurysmectomy by a closed heart technique, and Cooley, Collins, Morris, and Chapman (1958) reported the first open excision using cardiopulmonary bypass. Since then, a number of reports have been published on left ventricular aneurysmectomy with the use of cardiopulmonary bypass

Elective operations for post-infarction left ventricular aneurysms.

“…Selective coronary angiography indicates the feasibility of direct myocardial revascularization, which probably improves the long-term results (Davis et al, 1973;Merin et al, 1973;Gerbode et al, 1974;Cooperman et al, 1975). The usual haemodynamic parameters, such as the left ventricular end-diastolic pressure and the cardiac index, appear to have relatively little prognostic value (Key et al, 1968;Manvi, Allen and Ellestad, 1974;Cooperman et al, 1975).…”

“…As time is needed for the necrotic wall of the left ventricle to be converted into fibrous tissue, a time interval of three to six months between myocardial infarction and aneurysm resection has been quoted as critical to the results of surgery (Cooley and Hallman, 1968;Favaloro et al, 1968;Kluge et al, 1971;Gerbode et al, 1974). In our series, three patients were operated upon within three months of infarction; it is felt that no arbitary time lapse should be allowed to affect clinical judgement as to the timing of surgery.…”

“…Occasionally other mechanical problems, such as an associated ventricular septal defect or mitral regurgitation, also need correction. Combined revascularization should probably be undertaken in vessels that have considerable narrowing and still supply functioning myocardium (Thind, Blakemore, and Zinsser, 1971;Austen, 1973;Davis et al, 1973;Gerbode et al, 1974;Cooperman et al, 1975). This paper presents our clinical experience with the management of 20 consecutive patients by a reasonably aggressive surgical approach.…”