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A simple method of left ventricular reconstruction without patch for ischemic cardiomyopathy
A Simple Method of Left Ventricular Reconstruction Without Patch for Ischemic Cardiomyopathy Christiano Caldeira, MD, and Patrick M. McCarthy, MD Department of Thoracic and Cardiovascular Surgery, The Kaufman Center for Heart Failure, The Cleveland Clinic Foundation, Cleveland, Ohio
Interest in reconstructive surgery for ischemic cardiomyopathy has increased. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and threedimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation. (Ann Thorac Surg 2001;72:2148 –9) © 2001 by The Society of Thoracic Surgeons
I
nterest in reconstructive surgery for ischemic cardiomyopathy has increased as the heart failure population grows. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and three-dimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation [1].
Technique Coronary artery bypass and mitral valve repair are performed during cardioplegic arrest, then left ventricular reconstruction (LVR) is performed on the beating heart. The LV apex is opened 2 cm lateral to the left anterior descending (LAD) artery through the thin-walled scar. The ventriculotomy is extended proximally for 4 to 6 cm. LV thrombus is removed. A basket sucker is placed inside the left ventricle if there is aortic insufficiency. If there is a discreet rim of subendocardial scar, it is excised down to the “border zone,” the region where scar is contiguous with viable myocardium. For patients with a Accepted for publication Aug 18, 2001. Address reprint requests to Dr McCarthy, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-25, Cleveland, OH 44195; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (A) The aneurysm is opened 2 cm left of the left anterior descending artery. Stay sutures aid exposure. A purse-string suture is placed along the border zone into the scarred tissue. Palpation of the border zone in akinetic ventricles is useful. (B) The first suture has been tied and a second purse-string suture is used to create a smaller neck. 0003-4975/01/$20.00 PII S0003-4975(01)03242-8
Ann Thorac Surg 2001;72:2148 –9
HOW TO DO IT CALDEIRA AND McCARTHY LV RECONSTRUCTION WITHOUT PATCH
2149
5 cm. The second purse-string suture is placed 5 mm above the first purse-string suture (Fig 1B), and when tied, the neck is usually less than 2 cm. The LV is reconstructed to more of an ellipsoid shape (not globular), the residual chamber is reduced, and the infarcted anterior wall and septum are excluded. Strips of felt are placed on the LV epicardium and secured with 2-0 polypropylene (on an MH needle; Ethicon Inc) as horizontal mattress sutures. The sutures are passed from the felt through the left ventricle at the level of the purse string sutures, then up the septum and out the LV wall left of the LAD (Fig 2A). Care is taken not to pass the sutures through the LAD or the right ventricle. The ventriculotomy is oversewn with 2-0 polypropylene to eliminate bleeding. During closure, the LV apex is elevated, air is evacuated, and a vent is present in the aortic root. In cross-section, the anterior infarct is excluded and the reconstructed LV chamber is surrounded by viable LV muscle, with the exception of a thin rim of scar where the purse-string sutures were placed and reinforced with the mattress sutures (Fig 2B). The resultant LV chamber has no patch, and only a thin rim of noncontracting scar.
Comment
Fig 2. (A) Interrupted mattress sutures are passed through felt strips at the level of the purse-string sutures, then up to the left of the left anterior descending artery. (B) When visualized in cross-section, the anterior infarct is excluded, and the left ventricular chamber is surrounded by viable left ventricular muscle, with the exception of a thin rim of scar at the repair.
Using a patch to reconstruct the LAD infarct substitutes a smaller akinetic area (the patch) for the original aneurysm [1– 4]. Currently, we only use a patch in two situations: in patients with a calcified aneurysm in whom the purse-string sutures may not create a neck; and in rare patients with a small LV cavity that may be better reconstructed with a patch to avoid creating too small a cavity with a low stroke volume. The no-patch technique was performed in 102 patients from April 1998 until November 2000. Hospital mortality was 1%.
References history of ventricular tachycardia, cryolesions are placed at the border zone. The border zone is visible in dyskinetic infarcts, but in akinetic scars, palpation while the heart is beating is useful to identify the border zone. Two purse-string sutures of O polypropylene (on an MO-6 needle; Ethicon Inc, Somerville, NJ) are placed through the border zone 3 to 5 mm into the scarred tissue (Fig 1). Deep bites are taken into the scar tissue so that considerable tension can be applied. The first purse-string suture is tied, reducing the opening by 50% to 70%, creating a neck, usually 3 to
1. Qin JX, Shiota T, McCarthy PM, et al. Real-time three dimensional echocardiographic study of left ventricular function after infarct exclusion surgery for ischemic cardiomyopathy. Circulation 2000;102(Suppl III):101– 6. 2. Jatene AD. Left ventricular aneurysmectomy resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321–31. 3. Cooley DA. Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm. J Cardiac Surg 1989;4:200–5. 4. Dor V, Saab M, Coste P, et al. Left ventricular aneurysm: a new surgical approach. J Thorac Cardiovasc Surg 1989;37: 11–9.
Interest in reconstructive surgery for ischemic cardiomyopathy has increased. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and threedimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation. (Ann Thorac Surg 2001;72:2148 –9) © 2001 by The Society of Thoracic Surgeons
I
nterest in reconstructive surgery for ischemic cardiomyopathy has increased as the heart failure population grows. We prospectively studied patients undergoing left ventricular reconstruction for ischemic cardiomyopathy. This report describes our technique for no-patch repair of left anterior descending aneurysms or akinetic areas. Patients are selected for surgery with discreet left anterior descending scar, usually detected by preoperative magnetic resonance imaging scan and three-dimensional echocardiography, with compensated heart failure or other indications for surgery such as severe coronary artery disease or mitral regurgitation [1].
Technique Coronary artery bypass and mitral valve repair are performed during cardioplegic arrest, then left ventricular reconstruction (LVR) is performed on the beating heart. The LV apex is opened 2 cm lateral to the left anterior descending (LAD) artery through the thin-walled scar. The ventriculotomy is extended proximally for 4 to 6 cm. LV thrombus is removed. A basket sucker is placed inside the left ventricle if there is aortic insufficiency. If there is a discreet rim of subendocardial scar, it is excised down to the “border zone,” the region where scar is contiguous with viable myocardium. For patients with a Accepted for publication Aug 18, 2001. Address reprint requests to Dr McCarthy, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F-25, Cleveland, OH 44195; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (A) The aneurysm is opened 2 cm left of the left anterior descending artery. Stay sutures aid exposure. A purse-string suture is placed along the border zone into the scarred tissue. Palpation of the border zone in akinetic ventricles is useful. (B) The first suture has been tied and a second purse-string suture is used to create a smaller neck. 0003-4975/01/$20.00 PII S0003-4975(01)03242-8
Ann Thorac Surg 2001;72:2148 –9
HOW TO DO IT CALDEIRA AND McCARTHY LV RECONSTRUCTION WITHOUT PATCH
2149
5 cm. The second purse-string suture is placed 5 mm above the first purse-string suture (Fig 1B), and when tied, the neck is usually less than 2 cm. The LV is reconstructed to more of an ellipsoid shape (not globular), the residual chamber is reduced, and the infarcted anterior wall and septum are excluded. Strips of felt are placed on the LV epicardium and secured with 2-0 polypropylene (on an MH needle; Ethicon Inc) as horizontal mattress sutures. The sutures are passed from the felt through the left ventricle at the level of the purse string sutures, then up the septum and out the LV wall left of the LAD (Fig 2A). Care is taken not to pass the sutures through the LAD or the right ventricle. The ventriculotomy is oversewn with 2-0 polypropylene to eliminate bleeding. During closure, the LV apex is elevated, air is evacuated, and a vent is present in the aortic root. In cross-section, the anterior infarct is excluded and the reconstructed LV chamber is surrounded by viable LV muscle, with the exception of a thin rim of scar where the purse-string sutures were placed and reinforced with the mattress sutures (Fig 2B). The resultant LV chamber has no patch, and only a thin rim of noncontracting scar.
Comment
Fig 2. (A) Interrupted mattress sutures are passed through felt strips at the level of the purse-string sutures, then up to the left of the left anterior descending artery. (B) When visualized in cross-section, the anterior infarct is excluded, and the left ventricular chamber is surrounded by viable left ventricular muscle, with the exception of a thin rim of scar at the repair.
Using a patch to reconstruct the LAD infarct substitutes a smaller akinetic area (the patch) for the original aneurysm [1– 4]. Currently, we only use a patch in two situations: in patients with a calcified aneurysm in whom the purse-string sutures may not create a neck; and in rare patients with a small LV cavity that may be better reconstructed with a patch to avoid creating too small a cavity with a low stroke volume. The no-patch technique was performed in 102 patients from April 1998 until November 2000. Hospital mortality was 1%.
References history of ventricular tachycardia, cryolesions are placed at the border zone. The border zone is visible in dyskinetic infarcts, but in akinetic scars, palpation while the heart is beating is useful to identify the border zone. Two purse-string sutures of O polypropylene (on an MO-6 needle; Ethicon Inc, Somerville, NJ) are placed through the border zone 3 to 5 mm into the scarred tissue (Fig 1). Deep bites are taken into the scar tissue so that considerable tension can be applied. The first purse-string suture is tied, reducing the opening by 50% to 70%, creating a neck, usually 3 to
1. Qin JX, Shiota T, McCarthy PM, et al. Real-time three dimensional echocardiographic study of left ventricular function after infarct exclusion surgery for ischemic cardiomyopathy. Circulation 2000;102(Suppl III):101– 6. 2. Jatene AD. Left ventricular aneurysmectomy resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321–31. 3. Cooley DA. Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm. J Cardiac Surg 1989;4:200–5. 4. Dor V, Saab M, Coste P, et al. Left ventricular aneurysm: a new surgical approach. J Thorac Cardiovasc Surg 1989;37: 11–9.