Download Off-Pump Plication of Post MI Left Ventricular Aneurysm

Off Pump Plication of Post MI Left
Ventricular Aneurysm : Improve Cardiac
Function and Mitral Regurgitation
Dr. Ajeet Bana
Chairman – Cardiac Sciences
Eternal Heart Care Centre & Research Institute
Jaipur, Rajasthan, INDIA
Left Ventricular Aneurysm (LVA)
• LVA - common complication of MI.
• CASS definition- LV aneurysm is the segment of the LV
wall protruding from the expected outline of the
ventricular chamber and displaying either akinesis or
dyskinesis.
• Aneurysms distort LV elliptical geometry → ↓ LV
ejection volume → cardiac failure.
• Medical therapy ineffective, thus requiring surgical
intervention.
• Optimal surgical technique - ???
• Operative mortality (conventional) - 15%
• Many innovations, specifically for myocardial protection,
have been devised.
• Repair on Off Pump Beating Heart, to decrease mortality ,
is one of them which we have done in our study.
Methods
During (Jan.2010 – August 2013) – 9 pts.
(1) AWMI
(2) EF ≤ 30%
(3) Anterior aneurysm
(4) Grade II or III MR,
(5) No aneurysmal mural thrombus
Variable
Number of patients
Sex
Male
Female
Age ( Mean)
6
3
65.5 ± 6.2
Delay from MI
< 3 months
> 3 months
4
5
Dyspnoea
< Grade III
> Grade III
2
7
EF (%)
30.6 ± 5.4
MR
< Grade II
> Grade II
3
6
Surgical Technique
• Median sternotomy.
• OPCAB .
• LVA was confirmed visually & by palpation.
• Evaluated by TEE.
•
All thinned nonfunctioning portions of the wall were considered
for plication.
• Under TEE → plication - exclude nonfunctioning wall → restoring
ventricular size and shape using the modified linear closure.
Surgical Technique
• Two tissue stabilizers (spreaded suction pods) were applied.
• Multiple 2/0 prolene sutures (26mm needle) placed with
Teflon felt strip on both side of aneurysm in horizontal
mattress fashion.
• Needles entered into LV scar from lateral limit of aneurysm →
brought out of scar and re entered in LV aneurysm at 2-3 mm
distance → medial extension of aneurysm close to LAD.
• Sutures tightened in diastolic relaxation.
Surgical Technique
• Caution - not to pass sutures through the LAD or RV.
• Resultant LV - no patch, only a thin rim of noncontracting scar.
• In cross-section, the anterior infarction is excluded
and the reconstructed LV chamber is surrounded by
viable LV muscle, and reinforced with mattress
sutures.
Post-operative Period
Requirement of pre-op IABP
1
LCOS
1
Renal Impairment (S.Creat >2.0)
1
Arrhythmias
1
Duration of Ventilator support (hrs)
14.2 ± 3.8
ICU stay (days)
2.1 ± 1.3
Length of hospital stay (days)
10.8 ± 2.6
Comparison of Pre & Post-op ECHO
VARIABLES
LVEDD
EDVI
MR
EF (%)
PRE OP
63.3mm
131 ± 49 ml/m2
Grade II-III
30.6 ± 5.4
POST OP
52.8mm
102 ± 33 ml/m2
Grade I-II
35 ± 3.2
Results
• No in hospital mortality.
• CABG with average 3.2 grafts per patient.
• Significant improved in LVEF & LVEDD.
• Reduction in MR.
Follow-up
• 100% up to May 2015
• 1 Re-admission -
PCI to non-grafted vessel
(16 months)
• 1 ICD
-
9 months
• Echo
-
Maintained LV function & size
• Symptoms
-
Maintained symptomatic class
Concept
• (1) CABG - ↓ ischemia
• (2) LV Aneurysm repair
• ↓ ventricular volume
• Restoration of ventricular
geometry
• ↓ MR
Concept
(contd….)
• Aim of the plicating technique
– Spare the LV lateral wall
– Preserves systo-diastolic expansions of the viable
lateral myocardial wall, which frequently shows
normal contractile activity in patients with a
previous antero-septal infarction
Concept (contd….)
• Advantage of repair on the beating heart
without CPB –
• No ischemic time
• Easier decision-making for optimal restoration of
LV geometry
• By plicating nonfunctioning wall • ↓ chamber dimensions, wall tension & stress
• Restore LV geometry
Concept (contd….)
• ↓ in MR
• ↓ annular dilatation
• ↑ function of ischemic papillary muscle
• Re-alignment of papillary muscles
Pitfalls
• Scar related arrhythmias
• Posterior / inferior aneurysm
• Large aneurysm
• Delayed dilatation
Conclusion
• Our experience:
Aneurysm scar plication can be performed
– in severe coronary artery disease
– poor ventricular function
– low operative mortality
– good symptomatic improvement
– excellent survival
THANKS ……