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Natural history of saccular aneurysms of the left ventricle
Natural history of saccular aneurysms of the left ventricle We have studied the natural history of left ventricular aneurysms (LVA) in 40 patients not treated surgically who were followed for a mean period of 5 years, 8 months. These patients have been divided into two groups according to the presence (Group B) or absence (Group A) of significant symptomatology. The causes of death are dominated by arrhythmias and congestive heart failure (CHF). The survival rate at 10 years is 66.7 percent for the entire group. In asymptomatic patients the 10 year survival rate is 90 percent, but it is only 46.3 percent in those who were symptomatic at the time of the initial diagnosis. In general, the clinical course of survivors is stable in Group A but has deteriorated steadily in Group B. Nonfatal complications include arrhythmias (observed in 34 percent of all patients), thromboembolic phenomena (29 percent), CHF (29 percent), and recurrent myocardial infarction (22.5 percent). Factors influencing prognosis are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, the left ventricular end-diastolic pressure (LVEDP), and the presence of ventricular extrasystoles at the time of diagnosis. The mere presence of aneurysm is not, in itself: an indication for operation. Incapacitating angina and refractory CHF are the most valuable indications for surgical resection. The question is raised as to the value of operation in patients with little or no symptoms, in those with isolated life-threatening arrhythmias, and in those in whom a mural thrombus is the only distressing feature.
Pierre Grondin, M.D.,* J. Georges Kretz, M.D.* (by invitation), Olivier Bical, M.D. * (by invitation), Patrick Donzeau-Gouge, M.D. * (by invitation), Robert Petitclerc, M.D. ** (by invitation), and Lucien Campeau, M.D. *** (by invitation),
Montreal, Quebec, Canada
T
he natural history of left ventricular aneurysms (L VA) is poorly known. Most studies are retrospective and originate from autopsy cases.' These pathological surveys tend to demonstrate a rather grim outlook for patients with an aneurysm. Survival rates have been reported by Schlichter and associates! as 27 percent at 3 years and 12 percent at 5 years and by Schattenberg and colleagues" as 24 percent at 39 months. More recently, Proudfit**** has observed 74 living patients with this lesion having a 5 year survival rate of 47.3 percent and a 10 year rate of only 18.2 percent. From the Montreal Heart Institute, Montreal, Quebec, Canada. Read at the Fifty-eighth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., May 8, 9, and 10, 1978.
Address for reprints: Dr. Pierre Grondin, Director, Cardiovascular Center, St. Francis Hospital, 250 West 63rd St., Miami Beach, Fla. 33141. *Department of Surgery. **Department of Radiology. ***Department of Cardiology. ****Proudfit WL: Personal communication.
~ ~).. .
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.
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Natural history
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Fig. 1. Diagrammatic definition of distinction between aneurysm and other states of the left ventricle.
There is also a lack of agreement as to the definition of an L VA. Favaloro's group" described the lesion as "a full-thickness scar tissue replacement of a large segment of the L. V. wall, usually containing a thrombus and attached to the pericardial sac by adhesions." It is the purpose of this report to study the natural history of 40 patients in whom an LVA has been ra-
0022-5223/79/010057+08$00.80/0 © 1979 The C. V. Mosby Co.
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58
The Journal of Thoracic and Cardiovascular
Grondin et al,
Surgery
Table I. Reasons for conservative management
I
Anterolateral
~
~
LV
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Apical
4
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Posterobasal
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Diaphragmatic
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Fig. 2. Topographic distribution of the aneurysms encountered in the 40 patients (right anterior oblique projection).
diologically diagnosed and who were not operated upon for various reasons. This group was collected from consecutive patients investigated at the Montreal Heart Institute from 1964 to 1974. Only aneurysms associating an obvious diastolic bulge with a systolic paradoxical motion have been retained. We have therefore eliminated all other types of ventricular dysfunction such as hypokinesia, akinesia, and even those isolated types of dyskinesia with paradoxical motion, which in our experience do not represent true aneurysms, i.e., "fullthickness scar tissue replacement of a large segment of the L. V. wall" (Fig. I).
Methods The survey includes 40 cases of postinfarction saccular aneurysms of the left ventricle studied radiologically between 1964 and 1974. The diagnosis was based in 37 cases on a left ventricular angiogram (right anterior obligue view), with visualization of the coronary arteries in 36 cases. In three cases a multiple-incidence fluoroscopic study was sufficient to establish the diagnosis. The data were compared by the chi square and corrected chi square tests of Yates and by Fisher's exact test. Nonparametric data have been analyzed by the U test of Mann and Whitney. Actuarial survival curves have been established by the method of Cutler and Ederer. a
Patients The 40 patients (34 men and six women) were at a mean age of 46 years (28 to 65) when they had the myocardial infarction thought responsible for the aneurysm. They were at a mean age of 50 years (29 to 66)
Total No.
Group A (little or no symptoms) Group B (symptomatic) Refused operation Medical treatment preferred for arrhythmias Cardiac reasons "Bad" ventricle Nongraftable arteries Noncardiac reasons Respiratory insufficiency Renal failure (dialysis) Severe psychosis
20
Totals
~
4 4
2
4 5
3
40
7
when the aneurysm was discovered. There was a time interval of I month to 16 years (mean 4. I years) between the myocardial infarction and the discovery of an LVA. On April I, 1978, the mean period of follow-up of these patients was 5 years, 8 months (42 to 123 months). We evaluated the entire group on three separate occasions: in 1975, 1976, and 1978, and they were followed regularly by their own physicians as well. The clinical symptoms responsible for the initial diagnosis were angina in 17 instances, congestive heart failure (CHF) in seven, and arrhythmias in seven. Two patients had both angina and CHF. In 13 patients, the aneurysm was discovered on a routine postinfarction examination. On a clinical basis, the patients were divided into two groups: Group A comprised patients having mild or no symptoms and Group B, patients with significant symptoms and incapacity. Risk factors at the time of diagnosis included smoking in 24, dyslipidemia in 16, obesity in II, hypertension in eight, and diabetes in six cases. Coronary angiograms were performed in 36 instances. One patient had no demonstrable coronary artery lesion but had had an anterolateral myocardial infarction 16 months previously. All others had a greater than 50 percent stenosis of at least one major coronary artery. The left anterior descending was involved in 91.4 percent of cases, with complete occlusion in 21 and stenosis in 12 instances. The circumflex was affected in 48.5 percent, with stenosis in 15 and occlusion in two. The right coronary artery was diseased in 45.7 percent, being stenotic in nine and occluded in seven. In only three patients was significant involvement of the left main trunk demonstrated. The topographic distribution of the aneurysms was analyzed. In six cases only one segment (of five in the RAO projection) was affected: two anterolateral, two
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Saccular aneurysms of left ventricle
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January. 1979
Table II. Natural history Group A
Group B
Comparison
Deaths (mean follow-up: 5 yr., 8 mo.)
2/20
7/20
p = 0.0538
Survival rate at 10 yr. ('i1-)
90
46.3
66.7 (global)
Clinical course*
12 stable (I) 6 worsened (II)
8 stable (/I-III) 5 worsened (III-IV)
8 2 I
3 7 8
2
5
Nonfatal complications (No. pts.) Arrhythmias Thromboembolism Congestive heart failure Myocardial infarction
35% (of survivors) 29% (none with anticoag.) 33% of A}
100% of B
d' I on me rca treatment
22.5% or 4% per year
*New York Heart Association classification.
apical, one diaphragmatic. and one posterobasal. In 17 patients two segments were involved: the anterolateral and the apical. Finally, in 17, three segments were aneurysmal: the anterolateral, the apical, and the diaphragmatic segments. The location of these aneurysms was almost identical, 95 percent involving the anterolateral segment (Fig. 2). Thus the location of aneurysms in our series was similar to that in most surgical series reported in the literature. A total of 16 hypokinetic and one akinetic segments were associated with the aneurysmal segments in 10 cases. In 30 of 40 patients, the electrocardiogram showed the typical ST-segment displacement in the leads corresponding to the anatomic location of the aneurysm. An angiographic score was used to quantitate the severity of left ventricular dysfunction, one aneurysmal segment counting for 1 and one asynergic segment for 0.5. The ejection fraction of the nonaneurysmal portion of the left ventricle was calculated in 30 patients according to the method described by Watson and associates." The reasons for conservative management are listed in Table I. Among patients with symptoms, four refused operation, four were preferentially given medical therapy because arrhythmias were the main problem, nine had cardiac contraindications, including four who had a "bad" ventricle and five in whom the coronary arteries were judged "inadequate" for grafting, and finally three patients had serious extracardiac ailments-one each with respiratory insufficiency, severe and chronic psychosis, and chronic renal failure requiring repeated dialysis. We only observed the clinical course of these patients, leaving the therapeutic management to their respective physicians. Results Deaths. During the period of observation, nine of the 40 patients died: two in Group A and seven in Group B (Table II). This difference is at the limit of
statistical significance (p = 0.0538). The causes of death are dominated by arrhythmias (four cases) and CHF (three cases). One patient died of a myocardial infarction resulting from the occlusion of a dominant right coronary artery, and one patient already crippled by severe emphysema died of an infectious pneumonia. It is noteworthy that three of the four patients who died of ventricular arrhythmias had obvious ventricular extrasystoles at the time of the initial diagnosis, and two of them died within I month despite antiarrhythmic therapy. Survival. Actuarial survi val curves of the entire series demonstrate a survi val rate of 66.7 percent at 10 years (Fig. 3). Patients from Group A displayed a 10 year survival rate of 90 percent whereas those of Group B, only 46.3 percent. These curves are more optimistic than those of Proudfit (Fig. 4). However, in both series the number of patients surviving 10 years is rather small. Moreover, in our study the survi val rate at 10 years is exactly the same as at 6 years. This fact could be related in part to the close follow-up of these cases. Clinical course of survivors. Group A patients were all in Class I (New York Heart Association) for angina and dyspnea. Twelve have remained in stable condition and six have changed to Class II. Of the 13 survivors in Group B, eight have remained in Functional Class II or III and five have become more incapacitated-four Class III and one Class IV (Table II). Cardiothoracic index. The mean cardiothoracic index has increased from 49 to 50.3 percent. It is remarkable, that ventricular aneurysms, unlike arterial aneurysms remain relatively stable in size and have little or no tendency to expand. Nonfatal complications. Arrhythmias are the most frequently encountered fatal and nonfatal complications. Nonfatal arrhythmias were observed in 35 percent of all patients (Table II). The same arrhythmias are also plaguing the follow-up of most series of operated
60
The Joumal of Thoracic and Cardiovascular Surgery
Grondin et al.
% 100
90
GROUP A
80 70 ENTIRE GROUP
60
50 GROUP B
40
Group A and B survival rates Total group survival
30 20
Asymptomatic 000- - - " " Symptomatic •
10
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2
5
4
6
7
9
8
10
Years
Fig. 3. Actuarial survival curves of entire series. % 100 ......---<>---0----<>---0----<>---0---0 N.20 (a sympt 0 mat rc)
90
90%
80 70
M.H.!. (40 cases) 66.7%
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60
50
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40
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30
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candidates)
24%. >Proudflt 18.2% (74 cases)
20 10
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3
4
5
6
7
8
9
10 Years
Fig. 4. The actuarial survival curves of present series compared to that of Proudfit.
cases in which conventional surgical techniques were used.I"!" In our study, besides four instances of fatal arrhythmias, we have encountered two patients who had episodes of ventricular tachycardia, four with supraventricular tachycardia, two having repeated supraventricular extrasystoles, and three with auricular fibrillation and episodes of tachyarrhythmias. The majority of these patients were receiving long-term antiarrhythmic drugs. In contrast, none of nine patients who had thromboembolic phenomena were receiving anticoagulant therapy when this second most common complication occurred (29 percent). These episodes included one cerebrovascular accident with hemiplegia, one mesenteric infarction managed successfully by resection, one femoral embolism, and five transient episodes of cerebral ischemia without sequelae. However, at the time of their most recent evaluation, 22 of the 31 survivors were not receiving long-term anticoagulant therapy. It
is our contention that anticoagulation therapy is a worthwhile preventive measure in such patients. Recurrent myocardial infarction caused the death of one patient (Group B) 4 years, 5 months after the diagnosis of an LV A. Among the 31 survi vors were seven (two in Group A and five in Group B) who had another myocardial infarction after the formation of the ventricular aneurysm-an indidence of 22.5 percent or an annual rate of 4 percent. This 4 percent corresponds to the yearly incidence of infarction in patients having undergone aorta-coronary bypass in our institution. In itself the threat of recurrent infarction in patients with aneurysm does not justify surgical resection. Factors influencing prognosis (Table III) Extent of the aneurysm, symptoms, and survival. Many have stated that in the surgical management of LVA, the bigger the aneurysm, the better the results of operation. Size and extent are two different parameters.
Volume 77 Number 1
January. 1979
By extent we refer to the number of segments involved in the aneurysmal process, using the usual five segments described on the RAO ventriculogram. Extent in our study was directly related to the severity of symptoms and also to survival. Patients in Group A had a mean of two segments involved in the aneurysm, and patients in Group B had 2.5 segments affected (p < 0.025, U = 127). Of the 38 patients with one to three aneurysmal segments, seven died (18.4 percent). Two patients had more than three segments affected, and both died (p = 0.046). Associated asynergic segments. In 31 patients the aneurysm was isolated but in nine it was associated with one or two adjacent hypokinetic segments. The mortality rate was 16.1 percent (5/31) in isolated aneurysms versus 44.4 percent (4/9) in cases in which it was associated with hypokinetic segments (not statistically significant). However, when a contractility score (described previously) is used to quantitate the severity of left ventricular dysfunction, the survivors have a mean score of 2.3 and the patients who died, a score of 3.1. This is statistically valid (p < 0.01, Z = 2.236). Among other parameters affecting prognosis, we have also studied the ejection fraction of the residual left ventricle, the left ventricular end-diastolic pressure (L VEDP) at the time of diagnosis, the associated coronary artery disease, and the presence of ventricular extrasystoles at the time of the initial diagnosis. The mean ejection fraction of the nonsurvivors was 0.28 versus 0.44 for the survivors. This difference is statistically significant (p < 0.025, T = 2.43). All patients having an L VEDP of 15 mm. Hg or less at the time of diagnosis have survived; by contrast, among those with an L VEDP of 15 mm. Hg or more, eight have died. This difference is statistically significant (chi square C = 7.332, P < 0.05). The extent of the associated coronary disease, however, could not be related to a significant difference in long-term mortality rate: 9, zero, 30, and 30 percent, respectively, for one-, two-, and three-vessel disease or left main trunk disease. The presence of ventricular extrasystoles at the time of diagnosis was noted in three of the four patients who later died of ventricular arrhythmias. Discussion Gorlin and associates II have defined a ventricular aneurysm as a disturbance in ventricular motility or an asynergic area. We believe that this definition lacks precision. Along with others,": 12 we speak of L VA when there is a diastolic bulge of the left ventricle associated with a systolic paradoxical expansion.
Saccular aneurysms of left ventricle
6 I
Table III. Factors influencing prognosis
1
I. Extent (not size) of aneurysm Group A-2I5 segments involved 0 02 Group B-2.5/5 segments involved p < . 5 <3 segments (38 pts.)-18. 7% mortality} = 0046 >3 segments (2 pts.)-Ioo% mortality p . 2. Contractility score (1 segment aneurysmal = I; I segment hypokinetic 001 Survivors (31 Pts.)-2.3} Nonsurvivors (9 pts.)-3.1 p < .
= 0.5)
3. Ejection fraction of residual ventricle Survivors (31 pts.)-0.44 } < 0.025 Nonsurvivors (9 pts.)-0.28 p 4. Left ventricular end-diastolic pressure ,,; 15 mm. Hg (15 pts.)-no deaths} < 0.05 > 15 mm. Hg (21 pts.) -8 deaths p 5. Severity of coronary disease One vessel-9% mortality Two vessels-O% mortality Three vessels-30% mortality Left main trunk-30% mortality
1
6. Presence of ventricular extrasystoles (at diagnosis) Extrasystoles present (5 pts.)-3 deaths (60%) < 0.005 Extrasystoles absent (34 pts.)-I death (2.9%) P
The natural history of LV A remains the subject of much controversy. Pathological studies like those of Schlichter's group" and others': 13-15 suggest a poor survival. Moreover, several surveys of high-risk patients never treated surgically have produced similar conclusions." 14. 16 The study of Thompson and assoelates," however, is more optimistic. Of 14 patients followed for 56 months, only three have died. The results in surgically treated patients are better known. I H- 2o The operative mortality rate varies between 4.5 and 10 percent," 10. 21X25 but the late mortality rate is far from negligible.f": 27 Recent studies have reported an 18 percent late mortality rate after 31 months'" and a 19 percent rate after 3 years. 2; For a number of authors" 10 the role of an LV A in the production of CHF is such that the mere presence of an aneurysm constitutes a surgical indication. Our study reveals that asymptomatic patients have a satisfactory long-term outcome which justifies conservative management. However, when such patients have associated high-risk coronary artery lesions such as left main trunk and triple-vessel disease, surgical therapy may be indicated. When left ventricular mural thrombus is demonstrated in patients with no previous history of embolism and little or no symptoms, surgical resection remains controversial. The natural evolution of such thrombi needs to be evaluated further. Incapacitating angina is a good indication for opera-
62
The Journal of Thoracic and Cardiovascular
Grondin et al.
Surgery
tion, especially when the other two vessels (the right coronary and circumflex arteries) are normal. Resection alone will bring relief of angina in most instances. Moreover, when the aneurysm is associated with graftable lesions in the adjacent arteries, resection and grafting can be profitable, even though the operative mortality rate remains higher than for isolated aortacoronary bypass operations (4.5 to 10 percent versus 0.5 to 1.5 percent). However, with reduction in the operati ve risk by better myocardial protection (cold cardioplegia), these combined procedures may become less controversial. 7. 2,; Are isolated life-threatening arrhythmias a good indication for operation in LV A? So far the results of operation in such cases are conflicting.": 8. 25 Sami and Chabot;" from our institution, have demonstrated that many patients with L VA and serious arrhythmias are not relieved by operation and continued to require antiarrhythmic therapy. Electrophysiological studies have also showed that the sites of origin of the arrhythmias are frequently located in the margins or even away from the aneurysm itself. 29 Perioperative cardiac mapping may provide a satisfactory solution to this difficult problem, especially with the use of a new surgical technique described recently by Guiraudon and colleagues." Several reports": 31X33 have outlined factors relating to prognosis in surgically treated LV A. Brawley and colleagues? state that the occlusion of at least one major branch of the left anterior descending or the circumflex, when associated with lesions of two or three vessels, results in a poor prognosis. Operative mortality rate reaches 88 percent, versus 12.5 percent when an associated lesion is not encountered. Watson's group" emphasizes the importance of the ejection fraction of the residual ventricle on operative survival. Their data have been confirmed by others.": 34 The use of a singleplane (RAO) angiogram in the evaluation of LV A appears inadequate. For this reason, most authors recommend a biplane study. Mullen and associates" have insisted on the importance of septal contractility, which is demonstrated only in the LAO projection. In our study, the most important factors in establishing prognosis in ventricular aneurysms are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, and the L VEDP. To summarize, from our observations of the natural history of L VA, it seems that operation is indicated in incapacitating angina, previous thromboembolic phenomena, and refractory CHF. However, for patients with little or no symptoms, for those having isolated severe arrhythmias, and for those in whom a
mural thrombus has been demonstrated, the value of operation remains questionable at present. REFERENCES
2
3
4
5 6
7
8
9
10
II 12
13 14 15
16
17
Abrams DL, Edelist A, Luria MH, Miller Al: Ventricular aneurysm. A re-appraisal based on a study of sixty-five consecutive autopsied cases. Circulation 27: 164, 1963 Schlichter 1, Hellerstein HK, Katz LN: Aneurysm of the heart. A correlation study of 102 proved cases. Medicine 33:43, 1954 Schattenberg TT, Giuliani ER, Campion BC, Danielson GK lr: Post infarction ventricular aneurysm. Mayo Clin Proc 45:13, 1970 Favaloro RG, Effler DB, Groves LK, Wescott RN, Suarez E, Lozada 1: Ventricular aneurysm-clinical experience. Ann Thorac Surg 6:227, 1968 Cutler Sl, Ederer F: Maximum utilization of the life table method in analyzing survival. 1 Chron Dis 8:699, 1958 Watson LE, Dickhans DW, Martin RH: Left ventricular aneurysm. Preoperative hemodynamics, chamber volume and results of aneurysmectomy. Circulation 52:868, 1975 Brawley RK, Schaff H, Stevens R, Ducci H, Gott VL. Donahoo lS: Influence of coronary artery anatomy on survival following resection of left ventricular aneurysms and chronic infarcts. 1 THORAC CARDIOVASC SURG 73:120, 1977 Hazan E, Bloch G, Rioux C, Louville Y, Cirotteau Y. Mathey 1: Surgical treatment of aneurysm and segmental dyskinesia of the left ventricular wall after myocardial infarction. Am 1 Cardiol 31:708, 1973 Lee DCS, Johnson RA, Boucher CA, Wexler LF. McEnany MT: Left ventricular aneurysm. An analysis of survival in operated and unoperated patients (abstr). Circulation 54:Suppl 2:65, 1976 Loop FD, Effler DB, Navia lA, Sheldon WC, Groves LK: Aneurysms of the left ventricle. Survival and results of a ten-year surgical experience. Ann Surg 178:399. 1973 Gorlin R, Klein MD, Sullivan 1M: Prospective study of ventricular aneurysm. Am 1 Med 42:512, 1967 Heitz A, Campeau L, Grondin P: Anevrysmes et asynergies ventriculaires operes, Deuxieme partie. Aspects evolutifs, Coeur Med Int 15: 13, 1976 David RW, Ebert PA: Ventricular aneurysm, a clinical pathologic correlation. Am J Cardiol 29: I, 1972 Douglas AH, Sferrazza 1, Marici F: Natural history of aneurysm of ventricle. NY State J Med 15:209, 1962 Dubnow MH, Burchell HB, Titus lL: Postinfarction ventricular aneurysm. A clinico-morphologic and electrocardiographic study of 80 cases. Am Heart J 70:753, 1965 Bruschke A VG, Proudfit WL, Sones FM: Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. Circulation 47:Suppl 2: 1154, 1973 Thompson ME, Reddy PS, Haddock EP, Sundhal CG, Leon DF, Shaver lA, Bahnson HT: Patient prognosis
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Saccular aneurysms of left ventricle
Number 1
January, 1979
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24
25
26
27
28
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31
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with ventricular aneurysm. Medical versus surgical treatment, Coronary Artery Medicine and Surgery. Concepts and Controversies. lC Norman, ed., New York, 1975 Appleton-Century-Crofts, p 773 Fisher VI, Alvarez AI, Shah A, Dolgin M, Tice DA: Left ventricular scars. Clinical and hemodynamic results of excision. Br Heart J 36: 132, 1974 Gerbode F, Kerth WI, Hill 01, BanerJUS, Marcelletti C: Elective operation for left ventricular asynergy. Thorax 29:282, 1974 Moran 1M, Scan ion PI, Nemickas R, Pifarre R: Surgical treatment of post infarction ventricular aneurysm. Ann Thorac Surg 21:107,1976 Graber 10, Oakley CM, Pickering BN, Goodwin IF, Raphal MJ, Steiner RE: Ventricular aneurysm. An appraisal of diagnosis and surgical treatment. Br Heart 1 34:830, 1972 Key JA, Aldridge HE, MacGregor DC: The selection of patients for resection of left ventricular aneurysm. 1 THORAC CARDIOVASC SURG 56:477, 1968 Mullen DC, Posey L, Gabriel R, Singh HM, Flemma Rl, Lepley 0: Prognosis considerations in the management of left ventricular aneurysms. Ann Thorac Surg 23:455, 1977 Okies IE, Dietl C, Garrison HB, Starr A: Early and late results of resection of ventricular aneurysm. 1 THoRAc CARDIOVASC SURG 75:255, 1978 Shaw RC, Ferguson TB, Weldon CS, Connors IP. Left ventricular aneurysm resection. Indications and long term follow-up. Ann Thorac Surg 25:336, 1978 Cooperman M, Stinson EB, Griepp RB, Shumway NE: Survival and function after left ventricular aneurysmectomy. 1 THoRAc CARDIOVASC SURG 69:321, 1975 Hunyor SN, Bernstein L, Richmond 0, et al. Ventricular aneurysm-clinical features and place of surgical repair. Aust NZ 1 Med 3:239, 1971 Sami M, Charpin 0, Chabot M, Bourassa MG: Long term follow-up of aneurysmectomy for recurrent ventricular tachycardia or fibrillation. Am 1 Cardiol 39:269, 1977 Wittig JH, Boineau JF: Surgical treatment of ventricular arrhythmias using epicardial, transmural and endocardial mapping. Ann Thorac Surg 20:117,1975 Guiraudon G, Fontaine G, Frank R, Escand F, Cabrol C: Encircling endocardial ventriculotomy. A new surgical treatment for life-threatening ventricular tachycardia resistant to medical management following myocardial infarction. Ann Thorac Surg 26:438, 1978 Crawford OW, Barndt R, Harrison EC, Khan AH, Haywood Jl., Lau FYK: Ventricular aneurysm resection. Pre-operative estimation of postoperative result. Circulation 43, 44:Suppl 2: 155, 1971 Kitamura S, Echevarria M, Kay IH, et al: Left ventricular performance before and after removal of the noncontractile area from the left ventricle and revascularization of the myocardium. Circulation 45: 1005, 1972 Piessens 1, DeGeest H, Kesteloot H: Indications for sur-
63
gical treatment of left ventricular aneurysms. 1 Cardiovasc Surg 15:91, 1974 34 Arthur I, Basta L, Kioschos M: Factors influencing prognosis in left ventricular aneurysmectomy. Circulation 45, 46:Suppl 2: 127, 1972
Discussion DR. M.COSGROVE Cleveland. Ohio
We at the Cleveland Clinic agree with Dr. Grondin's conclusion that asymptomatic patients are seldom surgical candidates. In our surgical series of 348 consecutive cases, only five patients were operated upon who were asymptomatic. We believe, as has been demonstrated in all natural history studies of coronary artery disease, that ventricular function and extent of coronary artery disease are the principal determinants of survival, and we are surprised that Dr. Grondin's work does not confirm the latter. We noted in our surgical experience that the actuarial survival at 7 years was markedly divergent for single-, double-, and triple-vessel disease. We further found ventricular function to be a principal determinant of survival, as patients with preoperative CHF faired worse than those with other surgical indications. We continue to advocate an aggressive surgical approach to patients with all types of symptoms and have noted a steadily improving operative mortality rate, with one death in 74 patients last year. Because the extent of coronary artery disease is a principal determinant of survival, we believe that it is important to bypass all diseased vessels not involved in the aneurysm. As a result the percentage of patients receiving grafts in addition to aneurysmectomy has increased yearly and has now reached 85 percent. DR. CHRISTIAN E. CABROL Paris, France
As Dr. Grondin said, resection of LV A for the management of arrhythmias gives variable results. We have discovered the reason for this variability by the use of perioperative mapping: The origin of the arrhythmia, that is, the site of the "re-entry phenomenon" is usually not located in the aneurysmal sac but in adjacent areas or even in other myocardial scar, for example, in the septum or around the papillary muscles. In our group Dr. Guiraudon has developed a surgical technique which permits the interruption of this "re-entry phenomenon" by doing a peripheral endocardial myotomy from the inside of the ventricle. The operation is guided by epicardial mapping done before or at the beginning of cardiopulmonary bypass. This permits localization of the scar responsible for the arrhythmia. Then the left ventricle is opened either through the visible fibrous scar or by an incision at the apex. The white endocardial fibrous scar is easily seen, and an encircling myotomy is done from the inside to the outside through almost the full thickness of the parietal and/ or the septal wall. The myotomy is then closed by a single running suture.
The Journal of
64
Grondin et at.
The advantages of myotomy over resection are numerous. It does no harm to the papillary muscles or to the epicardial vessels. It can be applied to the septum, to a scar in any location, or to multiple scars. At the present time we have operated upon 7 such patients with no deaths and no recurrence of the arrhythmias. DR. G RON DIN (Closing) I am grateful to Dr. Cosgrove for his remarks. It is a fact, however, that we have found no correlation between the extent of the associated coronary artery disease and the survival of these nonoperated patients. If we use the classical division of one vessel, two vessels, three vessels, and left main coronary artery disease, our study shows a death rate of 9 percent for one-vessel disease, zero percent for two-vessel, 30 per-
Thoracic and Cardiovascular Surgery
cent for three-vessel, and 30 percent for left main trunk disease. These differences have no statistical validity. The surgical technique described by Dr. Cabrol for patients with life-threatening arrhythmias is promising. These arrhythmias have been a common indication for resection of ventricular aneurysm, but surgical results have been somewhat deceiving. Locating the focus of origin of these arrhythmias by electrocardiographic perioperative mapping requires a good deal of experience. However, with the possibility of correcting these arrhythmias by the technique described by Dr. Cabral, these efforts are worthwhile. The success of this type of operation will certainly change our approach to ventricular aneurysms associated with arrhythmias.
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January I, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.
Pierre Grondin, M.D.,* J. Georges Kretz, M.D.* (by invitation), Olivier Bical, M.D. * (by invitation), Patrick Donzeau-Gouge, M.D. * (by invitation), Robert Petitclerc, M.D. ** (by invitation), and Lucien Campeau, M.D. *** (by invitation),
Montreal, Quebec, Canada
T
he natural history of left ventricular aneurysms (L VA) is poorly known. Most studies are retrospective and originate from autopsy cases.' These pathological surveys tend to demonstrate a rather grim outlook for patients with an aneurysm. Survival rates have been reported by Schlichter and associates! as 27 percent at 3 years and 12 percent at 5 years and by Schattenberg and colleagues" as 24 percent at 39 months. More recently, Proudfit**** has observed 74 living patients with this lesion having a 5 year survival rate of 47.3 percent and a 10 year rate of only 18.2 percent. From the Montreal Heart Institute, Montreal, Quebec, Canada. Read at the Fifty-eighth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., May 8, 9, and 10, 1978.
Address for reprints: Dr. Pierre Grondin, Director, Cardiovascular Center, St. Francis Hospital, 250 West 63rd St., Miami Beach, Fla. 33141. *Department of Surgery. **Department of Radiology. ***Department of Cardiology. ****Proudfit WL: Personal communication.
~ ~).. .
\-
/ ....('-
· ( / tJ ..;....
. .
;.).
.
Akinesia
Normal
\;J tJ 1..I.
.)-.>->-......
Dyskinesia
..J
VENTRICULAR ANEURYSM
.
;).....
~\
Aneury~
....·)/
......
MH.I.
Natural history
-J
Diastole-Systole ..
Fig. 1. Diagrammatic definition of distinction between aneurysm and other states of the left ventricle.
There is also a lack of agreement as to the definition of an L VA. Favaloro's group" described the lesion as "a full-thickness scar tissue replacement of a large segment of the L. V. wall, usually containing a thrombus and attached to the pericardial sac by adhesions." It is the purpose of this report to study the natural history of 40 patients in whom an LVA has been ra-
0022-5223/79/010057+08$00.80/0 © 1979 The C. V. Mosby Co.
57
58
The Journal of Thoracic and Cardiovascular
Grondin et al,
Surgery
Table I. Reasons for conservative management
I
Anterolateral
~
~
LV
.>
[1ZJ
~
Apical
4
~
Posterobasal
Ifl
Diaphragmatic
rn
~
Fig. 2. Topographic distribution of the aneurysms encountered in the 40 patients (right anterior oblique projection).
diologically diagnosed and who were not operated upon for various reasons. This group was collected from consecutive patients investigated at the Montreal Heart Institute from 1964 to 1974. Only aneurysms associating an obvious diastolic bulge with a systolic paradoxical motion have been retained. We have therefore eliminated all other types of ventricular dysfunction such as hypokinesia, akinesia, and even those isolated types of dyskinesia with paradoxical motion, which in our experience do not represent true aneurysms, i.e., "fullthickness scar tissue replacement of a large segment of the L. V. wall" (Fig. I).
Methods The survey includes 40 cases of postinfarction saccular aneurysms of the left ventricle studied radiologically between 1964 and 1974. The diagnosis was based in 37 cases on a left ventricular angiogram (right anterior obligue view), with visualization of the coronary arteries in 36 cases. In three cases a multiple-incidence fluoroscopic study was sufficient to establish the diagnosis. The data were compared by the chi square and corrected chi square tests of Yates and by Fisher's exact test. Nonparametric data have been analyzed by the U test of Mann and Whitney. Actuarial survival curves have been established by the method of Cutler and Ederer. a
Patients The 40 patients (34 men and six women) were at a mean age of 46 years (28 to 65) when they had the myocardial infarction thought responsible for the aneurysm. They were at a mean age of 50 years (29 to 66)
Total No.
Group A (little or no symptoms) Group B (symptomatic) Refused operation Medical treatment preferred for arrhythmias Cardiac reasons "Bad" ventricle Nongraftable arteries Noncardiac reasons Respiratory insufficiency Renal failure (dialysis) Severe psychosis
20
Totals
~
4 4
2
4 5
3
40
7
when the aneurysm was discovered. There was a time interval of I month to 16 years (mean 4. I years) between the myocardial infarction and the discovery of an LVA. On April I, 1978, the mean period of follow-up of these patients was 5 years, 8 months (42 to 123 months). We evaluated the entire group on three separate occasions: in 1975, 1976, and 1978, and they were followed regularly by their own physicians as well. The clinical symptoms responsible for the initial diagnosis were angina in 17 instances, congestive heart failure (CHF) in seven, and arrhythmias in seven. Two patients had both angina and CHF. In 13 patients, the aneurysm was discovered on a routine postinfarction examination. On a clinical basis, the patients were divided into two groups: Group A comprised patients having mild or no symptoms and Group B, patients with significant symptoms and incapacity. Risk factors at the time of diagnosis included smoking in 24, dyslipidemia in 16, obesity in II, hypertension in eight, and diabetes in six cases. Coronary angiograms were performed in 36 instances. One patient had no demonstrable coronary artery lesion but had had an anterolateral myocardial infarction 16 months previously. All others had a greater than 50 percent stenosis of at least one major coronary artery. The left anterior descending was involved in 91.4 percent of cases, with complete occlusion in 21 and stenosis in 12 instances. The circumflex was affected in 48.5 percent, with stenosis in 15 and occlusion in two. The right coronary artery was diseased in 45.7 percent, being stenotic in nine and occluded in seven. In only three patients was significant involvement of the left main trunk demonstrated. The topographic distribution of the aneurysms was analyzed. In six cases only one segment (of five in the RAO projection) was affected: two anterolateral, two
Volume 77
Saccular aneurysms of left ventricle
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59
January. 1979
Table II. Natural history Group A
Group B
Comparison
Deaths (mean follow-up: 5 yr., 8 mo.)
2/20
7/20
p = 0.0538
Survival rate at 10 yr. ('i1-)
90
46.3
66.7 (global)
Clinical course*
12 stable (I) 6 worsened (II)
8 stable (/I-III) 5 worsened (III-IV)
8 2 I
3 7 8
2
5
Nonfatal complications (No. pts.) Arrhythmias Thromboembolism Congestive heart failure Myocardial infarction
35% (of survivors) 29% (none with anticoag.) 33% of A}
100% of B
d' I on me rca treatment
22.5% or 4% per year
*New York Heart Association classification.
apical, one diaphragmatic. and one posterobasal. In 17 patients two segments were involved: the anterolateral and the apical. Finally, in 17, three segments were aneurysmal: the anterolateral, the apical, and the diaphragmatic segments. The location of these aneurysms was almost identical, 95 percent involving the anterolateral segment (Fig. 2). Thus the location of aneurysms in our series was similar to that in most surgical series reported in the literature. A total of 16 hypokinetic and one akinetic segments were associated with the aneurysmal segments in 10 cases. In 30 of 40 patients, the electrocardiogram showed the typical ST-segment displacement in the leads corresponding to the anatomic location of the aneurysm. An angiographic score was used to quantitate the severity of left ventricular dysfunction, one aneurysmal segment counting for 1 and one asynergic segment for 0.5. The ejection fraction of the nonaneurysmal portion of the left ventricle was calculated in 30 patients according to the method described by Watson and associates." The reasons for conservative management are listed in Table I. Among patients with symptoms, four refused operation, four were preferentially given medical therapy because arrhythmias were the main problem, nine had cardiac contraindications, including four who had a "bad" ventricle and five in whom the coronary arteries were judged "inadequate" for grafting, and finally three patients had serious extracardiac ailments-one each with respiratory insufficiency, severe and chronic psychosis, and chronic renal failure requiring repeated dialysis. We only observed the clinical course of these patients, leaving the therapeutic management to their respective physicians. Results Deaths. During the period of observation, nine of the 40 patients died: two in Group A and seven in Group B (Table II). This difference is at the limit of
statistical significance (p = 0.0538). The causes of death are dominated by arrhythmias (four cases) and CHF (three cases). One patient died of a myocardial infarction resulting from the occlusion of a dominant right coronary artery, and one patient already crippled by severe emphysema died of an infectious pneumonia. It is noteworthy that three of the four patients who died of ventricular arrhythmias had obvious ventricular extrasystoles at the time of the initial diagnosis, and two of them died within I month despite antiarrhythmic therapy. Survival. Actuarial survi val curves of the entire series demonstrate a survi val rate of 66.7 percent at 10 years (Fig. 3). Patients from Group A displayed a 10 year survival rate of 90 percent whereas those of Group B, only 46.3 percent. These curves are more optimistic than those of Proudfit (Fig. 4). However, in both series the number of patients surviving 10 years is rather small. Moreover, in our study the survi val rate at 10 years is exactly the same as at 6 years. This fact could be related in part to the close follow-up of these cases. Clinical course of survivors. Group A patients were all in Class I (New York Heart Association) for angina and dyspnea. Twelve have remained in stable condition and six have changed to Class II. Of the 13 survivors in Group B, eight have remained in Functional Class II or III and five have become more incapacitated-four Class III and one Class IV (Table II). Cardiothoracic index. The mean cardiothoracic index has increased from 49 to 50.3 percent. It is remarkable, that ventricular aneurysms, unlike arterial aneurysms remain relatively stable in size and have little or no tendency to expand. Nonfatal complications. Arrhythmias are the most frequently encountered fatal and nonfatal complications. Nonfatal arrhythmias were observed in 35 percent of all patients (Table II). The same arrhythmias are also plaguing the follow-up of most series of operated
60
The Joumal of Thoracic and Cardiovascular Surgery
Grondin et al.
% 100
90
GROUP A
80 70 ENTIRE GROUP
60
50 GROUP B
40
Group A and B survival rates Total group survival
30 20
Asymptomatic 000- - - " " Symptomatic •
10
O..........,........,.......,-,......,.....,......,......,~.,......,.... 3
2
5
4
6
7
9
8
10
Years
Fig. 3. Actuarial survival curves of entire series. % 100 ......---<>---0----<>---0----<>---0---0 N.20 (a sympt 0 mat rc)
90
90%
80 70
M.H.!. (40 cases) 66.7%
~-------------
60
50
"'-,;.",.:_-0----<>---0 N.20 (symptomatic)
40
(2:6s~~.
....................
30
.........•
candidates)
24%. >Proudflt 18.2% (74 cases)
20 10
O.........,......,.......,-,......,....,......,.-,....-"T""""'T"'" 2
3
4
5
6
7
8
9
10 Years
Fig. 4. The actuarial survival curves of present series compared to that of Proudfit.
cases in which conventional surgical techniques were used.I"!" In our study, besides four instances of fatal arrhythmias, we have encountered two patients who had episodes of ventricular tachycardia, four with supraventricular tachycardia, two having repeated supraventricular extrasystoles, and three with auricular fibrillation and episodes of tachyarrhythmias. The majority of these patients were receiving long-term antiarrhythmic drugs. In contrast, none of nine patients who had thromboembolic phenomena were receiving anticoagulant therapy when this second most common complication occurred (29 percent). These episodes included one cerebrovascular accident with hemiplegia, one mesenteric infarction managed successfully by resection, one femoral embolism, and five transient episodes of cerebral ischemia without sequelae. However, at the time of their most recent evaluation, 22 of the 31 survivors were not receiving long-term anticoagulant therapy. It
is our contention that anticoagulation therapy is a worthwhile preventive measure in such patients. Recurrent myocardial infarction caused the death of one patient (Group B) 4 years, 5 months after the diagnosis of an LV A. Among the 31 survi vors were seven (two in Group A and five in Group B) who had another myocardial infarction after the formation of the ventricular aneurysm-an indidence of 22.5 percent or an annual rate of 4 percent. This 4 percent corresponds to the yearly incidence of infarction in patients having undergone aorta-coronary bypass in our institution. In itself the threat of recurrent infarction in patients with aneurysm does not justify surgical resection. Factors influencing prognosis (Table III) Extent of the aneurysm, symptoms, and survival. Many have stated that in the surgical management of LVA, the bigger the aneurysm, the better the results of operation. Size and extent are two different parameters.
Volume 77 Number 1
January. 1979
By extent we refer to the number of segments involved in the aneurysmal process, using the usual five segments described on the RAO ventriculogram. Extent in our study was directly related to the severity of symptoms and also to survival. Patients in Group A had a mean of two segments involved in the aneurysm, and patients in Group B had 2.5 segments affected (p < 0.025, U = 127). Of the 38 patients with one to three aneurysmal segments, seven died (18.4 percent). Two patients had more than three segments affected, and both died (p = 0.046). Associated asynergic segments. In 31 patients the aneurysm was isolated but in nine it was associated with one or two adjacent hypokinetic segments. The mortality rate was 16.1 percent (5/31) in isolated aneurysms versus 44.4 percent (4/9) in cases in which it was associated with hypokinetic segments (not statistically significant). However, when a contractility score (described previously) is used to quantitate the severity of left ventricular dysfunction, the survivors have a mean score of 2.3 and the patients who died, a score of 3.1. This is statistically valid (p < 0.01, Z = 2.236). Among other parameters affecting prognosis, we have also studied the ejection fraction of the residual left ventricle, the left ventricular end-diastolic pressure (L VEDP) at the time of diagnosis, the associated coronary artery disease, and the presence of ventricular extrasystoles at the time of the initial diagnosis. The mean ejection fraction of the nonsurvivors was 0.28 versus 0.44 for the survivors. This difference is statistically significant (p < 0.025, T = 2.43). All patients having an L VEDP of 15 mm. Hg or less at the time of diagnosis have survived; by contrast, among those with an L VEDP of 15 mm. Hg or more, eight have died. This difference is statistically significant (chi square C = 7.332, P < 0.05). The extent of the associated coronary disease, however, could not be related to a significant difference in long-term mortality rate: 9, zero, 30, and 30 percent, respectively, for one-, two-, and three-vessel disease or left main trunk disease. The presence of ventricular extrasystoles at the time of diagnosis was noted in three of the four patients who later died of ventricular arrhythmias. Discussion Gorlin and associates II have defined a ventricular aneurysm as a disturbance in ventricular motility or an asynergic area. We believe that this definition lacks precision. Along with others,": 12 we speak of L VA when there is a diastolic bulge of the left ventricle associated with a systolic paradoxical expansion.
Saccular aneurysms of left ventricle
6 I
Table III. Factors influencing prognosis
1
I. Extent (not size) of aneurysm Group A-2I5 segments involved 0 02 Group B-2.5/5 segments involved p < . 5 <3 segments (38 pts.)-18. 7% mortality} = 0046 >3 segments (2 pts.)-Ioo% mortality p . 2. Contractility score (1 segment aneurysmal = I; I segment hypokinetic 001 Survivors (31 Pts.)-2.3} Nonsurvivors (9 pts.)-3.1 p < .
= 0.5)
3. Ejection fraction of residual ventricle Survivors (31 pts.)-0.44 } < 0.025 Nonsurvivors (9 pts.)-0.28 p 4. Left ventricular end-diastolic pressure ,,; 15 mm. Hg (15 pts.)-no deaths} < 0.05 > 15 mm. Hg (21 pts.) -8 deaths p 5. Severity of coronary disease One vessel-9% mortality Two vessels-O% mortality Three vessels-30% mortality Left main trunk-30% mortality
1
6. Presence of ventricular extrasystoles (at diagnosis) Extrasystoles present (5 pts.)-3 deaths (60%) < 0.005 Extrasystoles absent (34 pts.)-I death (2.9%) P
The natural history of LV A remains the subject of much controversy. Pathological studies like those of Schlichter's group" and others': 13-15 suggest a poor survival. Moreover, several surveys of high-risk patients never treated surgically have produced similar conclusions." 14. 16 The study of Thompson and assoelates," however, is more optimistic. Of 14 patients followed for 56 months, only three have died. The results in surgically treated patients are better known. I H- 2o The operative mortality rate varies between 4.5 and 10 percent," 10. 21X25 but the late mortality rate is far from negligible.f": 27 Recent studies have reported an 18 percent late mortality rate after 31 months'" and a 19 percent rate after 3 years. 2; For a number of authors" 10 the role of an LV A in the production of CHF is such that the mere presence of an aneurysm constitutes a surgical indication. Our study reveals that asymptomatic patients have a satisfactory long-term outcome which justifies conservative management. However, when such patients have associated high-risk coronary artery lesions such as left main trunk and triple-vessel disease, surgical therapy may be indicated. When left ventricular mural thrombus is demonstrated in patients with no previous history of embolism and little or no symptoms, surgical resection remains controversial. The natural evolution of such thrombi needs to be evaluated further. Incapacitating angina is a good indication for opera-
62
The Journal of Thoracic and Cardiovascular
Grondin et al.
Surgery
tion, especially when the other two vessels (the right coronary and circumflex arteries) are normal. Resection alone will bring relief of angina in most instances. Moreover, when the aneurysm is associated with graftable lesions in the adjacent arteries, resection and grafting can be profitable, even though the operative mortality rate remains higher than for isolated aortacoronary bypass operations (4.5 to 10 percent versus 0.5 to 1.5 percent). However, with reduction in the operati ve risk by better myocardial protection (cold cardioplegia), these combined procedures may become less controversial. 7. 2,; Are isolated life-threatening arrhythmias a good indication for operation in LV A? So far the results of operation in such cases are conflicting.": 8. 25 Sami and Chabot;" from our institution, have demonstrated that many patients with L VA and serious arrhythmias are not relieved by operation and continued to require antiarrhythmic therapy. Electrophysiological studies have also showed that the sites of origin of the arrhythmias are frequently located in the margins or even away from the aneurysm itself. 29 Perioperative cardiac mapping may provide a satisfactory solution to this difficult problem, especially with the use of a new surgical technique described recently by Guiraudon and colleagues." Several reports": 31X33 have outlined factors relating to prognosis in surgically treated LV A. Brawley and colleagues? state that the occlusion of at least one major branch of the left anterior descending or the circumflex, when associated with lesions of two or three vessels, results in a poor prognosis. Operative mortality rate reaches 88 percent, versus 12.5 percent when an associated lesion is not encountered. Watson's group" emphasizes the importance of the ejection fraction of the residual ventricle on operative survival. Their data have been confirmed by others.": 34 The use of a singleplane (RAO) angiogram in the evaluation of LV A appears inadequate. For this reason, most authors recommend a biplane study. Mullen and associates" have insisted on the importance of septal contractility, which is demonstrated only in the LAO projection. In our study, the most important factors in establishing prognosis in ventricular aneurysms are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, and the L VEDP. To summarize, from our observations of the natural history of L VA, it seems that operation is indicated in incapacitating angina, previous thromboembolic phenomena, and refractory CHF. However, for patients with little or no symptoms, for those having isolated severe arrhythmias, and for those in whom a
mural thrombus has been demonstrated, the value of operation remains questionable at present. REFERENCES
2
3
4
5 6
7
8
9
10
II 12
13 14 15
16
17
Abrams DL, Edelist A, Luria MH, Miller Al: Ventricular aneurysm. A re-appraisal based on a study of sixty-five consecutive autopsied cases. Circulation 27: 164, 1963 Schlichter 1, Hellerstein HK, Katz LN: Aneurysm of the heart. A correlation study of 102 proved cases. Medicine 33:43, 1954 Schattenberg TT, Giuliani ER, Campion BC, Danielson GK lr: Post infarction ventricular aneurysm. Mayo Clin Proc 45:13, 1970 Favaloro RG, Effler DB, Groves LK, Wescott RN, Suarez E, Lozada 1: Ventricular aneurysm-clinical experience. Ann Thorac Surg 6:227, 1968 Cutler Sl, Ederer F: Maximum utilization of the life table method in analyzing survival. 1 Chron Dis 8:699, 1958 Watson LE, Dickhans DW, Martin RH: Left ventricular aneurysm. Preoperative hemodynamics, chamber volume and results of aneurysmectomy. Circulation 52:868, 1975 Brawley RK, Schaff H, Stevens R, Ducci H, Gott VL. Donahoo lS: Influence of coronary artery anatomy on survival following resection of left ventricular aneurysms and chronic infarcts. 1 THORAC CARDIOVASC SURG 73:120, 1977 Hazan E, Bloch G, Rioux C, Louville Y, Cirotteau Y. Mathey 1: Surgical treatment of aneurysm and segmental dyskinesia of the left ventricular wall after myocardial infarction. Am 1 Cardiol 31:708, 1973 Lee DCS, Johnson RA, Boucher CA, Wexler LF. McEnany MT: Left ventricular aneurysm. An analysis of survival in operated and unoperated patients (abstr). Circulation 54:Suppl 2:65, 1976 Loop FD, Effler DB, Navia lA, Sheldon WC, Groves LK: Aneurysms of the left ventricle. Survival and results of a ten-year surgical experience. Ann Surg 178:399. 1973 Gorlin R, Klein MD, Sullivan 1M: Prospective study of ventricular aneurysm. Am 1 Med 42:512, 1967 Heitz A, Campeau L, Grondin P: Anevrysmes et asynergies ventriculaires operes, Deuxieme partie. Aspects evolutifs, Coeur Med Int 15: 13, 1976 David RW, Ebert PA: Ventricular aneurysm, a clinical pathologic correlation. Am J Cardiol 29: I, 1972 Douglas AH, Sferrazza 1, Marici F: Natural history of aneurysm of ventricle. NY State J Med 15:209, 1962 Dubnow MH, Burchell HB, Titus lL: Postinfarction ventricular aneurysm. A clinico-morphologic and electrocardiographic study of 80 cases. Am Heart J 70:753, 1965 Bruschke A VG, Proudfit WL, Sones FM: Progress study of 590 consecutive nonsurgical cases of coronary disease followed 5-9 years. Circulation 47:Suppl 2: 1154, 1973 Thompson ME, Reddy PS, Haddock EP, Sundhal CG, Leon DF, Shaver lA, Bahnson HT: Patient prognosis
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Saccular aneurysms of left ventricle
Number 1
January, 1979
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
with ventricular aneurysm. Medical versus surgical treatment, Coronary Artery Medicine and Surgery. Concepts and Controversies. lC Norman, ed., New York, 1975 Appleton-Century-Crofts, p 773 Fisher VI, Alvarez AI, Shah A, Dolgin M, Tice DA: Left ventricular scars. Clinical and hemodynamic results of excision. Br Heart J 36: 132, 1974 Gerbode F, Kerth WI, Hill 01, BanerJUS, Marcelletti C: Elective operation for left ventricular asynergy. Thorax 29:282, 1974 Moran 1M, Scan ion PI, Nemickas R, Pifarre R: Surgical treatment of post infarction ventricular aneurysm. Ann Thorac Surg 21:107,1976 Graber 10, Oakley CM, Pickering BN, Goodwin IF, Raphal MJ, Steiner RE: Ventricular aneurysm. An appraisal of diagnosis and surgical treatment. Br Heart 1 34:830, 1972 Key JA, Aldridge HE, MacGregor DC: The selection of patients for resection of left ventricular aneurysm. 1 THORAC CARDIOVASC SURG 56:477, 1968 Mullen DC, Posey L, Gabriel R, Singh HM, Flemma Rl, Lepley 0: Prognosis considerations in the management of left ventricular aneurysms. Ann Thorac Surg 23:455, 1977 Okies IE, Dietl C, Garrison HB, Starr A: Early and late results of resection of ventricular aneurysm. 1 THoRAc CARDIOVASC SURG 75:255, 1978 Shaw RC, Ferguson TB, Weldon CS, Connors IP. Left ventricular aneurysm resection. Indications and long term follow-up. Ann Thorac Surg 25:336, 1978 Cooperman M, Stinson EB, Griepp RB, Shumway NE: Survival and function after left ventricular aneurysmectomy. 1 THoRAc CARDIOVASC SURG 69:321, 1975 Hunyor SN, Bernstein L, Richmond 0, et al. Ventricular aneurysm-clinical features and place of surgical repair. Aust NZ 1 Med 3:239, 1971 Sami M, Charpin 0, Chabot M, Bourassa MG: Long term follow-up of aneurysmectomy for recurrent ventricular tachycardia or fibrillation. Am 1 Cardiol 39:269, 1977 Wittig JH, Boineau JF: Surgical treatment of ventricular arrhythmias using epicardial, transmural and endocardial mapping. Ann Thorac Surg 20:117,1975 Guiraudon G, Fontaine G, Frank R, Escand F, Cabrol C: Encircling endocardial ventriculotomy. A new surgical treatment for life-threatening ventricular tachycardia resistant to medical management following myocardial infarction. Ann Thorac Surg 26:438, 1978 Crawford OW, Barndt R, Harrison EC, Khan AH, Haywood Jl., Lau FYK: Ventricular aneurysm resection. Pre-operative estimation of postoperative result. Circulation 43, 44:Suppl 2: 155, 1971 Kitamura S, Echevarria M, Kay IH, et al: Left ventricular performance before and after removal of the noncontractile area from the left ventricle and revascularization of the myocardium. Circulation 45: 1005, 1972 Piessens 1, DeGeest H, Kesteloot H: Indications for sur-
63
gical treatment of left ventricular aneurysms. 1 Cardiovasc Surg 15:91, 1974 34 Arthur I, Basta L, Kioschos M: Factors influencing prognosis in left ventricular aneurysmectomy. Circulation 45, 46:Suppl 2: 127, 1972
Discussion DR. M.COSGROVE Cleveland. Ohio
We at the Cleveland Clinic agree with Dr. Grondin's conclusion that asymptomatic patients are seldom surgical candidates. In our surgical series of 348 consecutive cases, only five patients were operated upon who were asymptomatic. We believe, as has been demonstrated in all natural history studies of coronary artery disease, that ventricular function and extent of coronary artery disease are the principal determinants of survival, and we are surprised that Dr. Grondin's work does not confirm the latter. We noted in our surgical experience that the actuarial survival at 7 years was markedly divergent for single-, double-, and triple-vessel disease. We further found ventricular function to be a principal determinant of survival, as patients with preoperative CHF faired worse than those with other surgical indications. We continue to advocate an aggressive surgical approach to patients with all types of symptoms and have noted a steadily improving operative mortality rate, with one death in 74 patients last year. Because the extent of coronary artery disease is a principal determinant of survival, we believe that it is important to bypass all diseased vessels not involved in the aneurysm. As a result the percentage of patients receiving grafts in addition to aneurysmectomy has increased yearly and has now reached 85 percent. DR. CHRISTIAN E. CABROL Paris, France
As Dr. Grondin said, resection of LV A for the management of arrhythmias gives variable results. We have discovered the reason for this variability by the use of perioperative mapping: The origin of the arrhythmia, that is, the site of the "re-entry phenomenon" is usually not located in the aneurysmal sac but in adjacent areas or even in other myocardial scar, for example, in the septum or around the papillary muscles. In our group Dr. Guiraudon has developed a surgical technique which permits the interruption of this "re-entry phenomenon" by doing a peripheral endocardial myotomy from the inside of the ventricle. The operation is guided by epicardial mapping done before or at the beginning of cardiopulmonary bypass. This permits localization of the scar responsible for the arrhythmia. Then the left ventricle is opened either through the visible fibrous scar or by an incision at the apex. The white endocardial fibrous scar is easily seen, and an encircling myotomy is done from the inside to the outside through almost the full thickness of the parietal and/ or the septal wall. The myotomy is then closed by a single running suture.
The Journal of
64
Grondin et at.
The advantages of myotomy over resection are numerous. It does no harm to the papillary muscles or to the epicardial vessels. It can be applied to the septum, to a scar in any location, or to multiple scars. At the present time we have operated upon 7 such patients with no deaths and no recurrence of the arrhythmias. DR. G RON DIN (Closing) I am grateful to Dr. Cosgrove for his remarks. It is a fact, however, that we have found no correlation between the extent of the associated coronary artery disease and the survival of these nonoperated patients. If we use the classical division of one vessel, two vessels, three vessels, and left main coronary artery disease, our study shows a death rate of 9 percent for one-vessel disease, zero percent for two-vessel, 30 per-
Thoracic and Cardiovascular Surgery
cent for three-vessel, and 30 percent for left main trunk disease. These differences have no statistical validity. The surgical technique described by Dr. Cabrol for patients with life-threatening arrhythmias is promising. These arrhythmias have been a common indication for resection of ventricular aneurysm, but surgical results have been somewhat deceiving. Locating the focus of origin of these arrhythmias by electrocardiographic perioperative mapping requires a good deal of experience. However, with the possibility of correcting these arrhythmias by the technique described by Dr. Cabral, these efforts are worthwhile. The success of this type of operation will certainly change our approach to ventricular aneurysms associated with arrhythmias.
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January I, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: "The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors." Authors will be consulted, when possible, regarding republication of their material.