1. Ventricular resection in cardiac failure
Surendra Naidoo
Cardiothoracic Surgery
Durban

2. Ventricular aneurysm resection
Definition
strictly - distinct area of abnormal left ventricular diastolic contour with systolic dyskinesia or paradoxical bulging
loosely…
intraoperative…

3. Pathophysiology Early expansion phase onset of MI
gross thinning of infarct zone
endocardium is smooth
deposition of fibrin & thrombus
Laplace's law (T = Pr/2h)
Late remodelling phase
2 – 4 weeks after MI
granulation tissue replaced by fibrous tissue
mural thrombus

4. Indications for surgery
Asymptomatic
incidental
during CABG
moderate size
CASS Study
Relative contraindications to operation for left ventricular aneurysm include excessive anesthetic risk, impaired function of residual myocardium outside the aneurysm, resting cardiac index less than 2.0 L/min/m2, significant mitral regurgitation, evidence of nontransmural infarction (hibernating myocardium), and lack of a discrete, thin-walled aneurysm with distinct margins.

5. Indications for surgery
Symptomatic
CHF
angina
arrhythmias
embolism

6. Techniques General CPB VF cardioplegic arrest epicardial mapping
Off-pump

7. Techniques Plication Linear closure Circular patch
Endoventricular patch

8. Plication small aneurysms no mural thrombus two-layer suture line
strip of Teflon felt
does not exclude all aneurysmal tissue

9. Linear closure remove mural thrombus
suture may be used to reduce the neck
Teflon felt
two layers horizontal mattress suture
two layers running vertical sutures

10. 51 yr. old inferoposterior MI 08 / 2006

19. Modified linear closure

20. Circular patch inferior or posterior aneurysms dacron patch
interrupted horizontal mattress sutures
second layer placed for hemostasis

25. Endoventricular patch
defect <3 cm – linear closure
patch sutured to normal muscle
rim is trimmed - allow primary closure of the native aneurysmal wall

28. Jatene vs. Dor cardiac arrest transitional suture patch type anchoring
closure

30. Ventricular resection Partial left ventriculectomy (PLV)
Batista
Lateral
extended
Anterior

31. Results 153 references 99 articles reporting case series or case
reports
Non-randomised comparative studies - 1
Case series – 3
sample size
completeness of reporting

33. Results Operative survival – PLV 94%; OHT 94% (
12-month survival from time of surgery – PLV 86%; OHT 93%
12-month survival from time of listing – 86% PLV; 75% OHT
12-month freedom from death or relisting for transplant – PLV 65%; OHT 86%
Freedom from need for relisting for transplant – PLV 73%; OHT 93%
Relisting for transplant – 4 PLV (2 LVAD placements in meantime); 1 OHT
Post-op mortality – 2 PLV (sepsis –1, heart failure –1); 1 transplant
Results
Etoch et al. 1999
Retrospective comparative study of PLV vs transplantation
October 1996-April 1998
N=45
PLV – 16
OHT – 29
Mean follow-up: 11.1 months PLV, 16.4 months OHT
Selection criteria
idiopathic dilated
cardiomyopathy
NYHA IV despite
maximal medical therapy

34. Fujimura et al. 2001; Kawaguchi et al. 2001, 1998
Survival: - early postoperative
30 days – 75% anterior PLV, 72% lateral PLV, 50% extended PLV
60 days – 75% anterior PLV, 70% lateral PLV, 45% extended PLV
Survival time – 13.6 months
Hospital deaths – 138 (30%)
cardiac failure – 27
renal failure – 23
arrhythmia – 13
noncardiac causes – 7
miscellaneous – 5
undetermined – 52
Died after discharge – 44 (9.5%)
Overall mortality – 182 (39.5%)
Fujimura et al. 2001; Kawaguchi et al. 2001, 1998
August 1994 – March 1997
N=461
Lateral PLV 295
Extended PLV 101
Anterior PLV 65
Follow-up: 13.6 months
Selection criteria:
cardiomyopathy
coronary artery disease
valvular disease
Chagas disease

35. Franco-Cereceda et al. 2001; Starling & McCarthy, 1999; McCarthy et al
USA ( Cleveland Clinic)
May 1996 – December 1998
N=62
Mean follow-up: 24 mnths
Selection criteria:
LVEDD > 7.0cm
dilated cardiomyopathy without extensive scar tissue
no medical contraindications
NYHA III/IV
heart failure > 6months
optimised on medical therapy for heart failure prior to surgery
Echo: LVEF 16[7.6] to 31.5[10.9] (p<0.0001)
Survival:
survival 30 days – 99%
survival 3 years – 60%
event-free survival 30 days – 80%
event-free survival 3 years – 26%
LVAD rescue therapy: 11
Return to class IV HF: – 32
Freedom from class IV HF 30 days – 81%
Freedom from class IV HF 1 year – 57%
Freedom from class IV HF 3 years – 42%
hospital deaths – 2
risk of death - 6%/month in early phase (up to 4 months);1.2/month (by 12 months)
Mortality causes:
HF/arrhythmias – 11
sudden death – 4
multiorgan failure – 4
stroke – 1
witnessed cardiac arrest – 1

36. Hospital Angelina Caron – 50 Buffalo General Hospital – 70
Postoperatively:
NYHA functional class I – 57%
NYHA functional class II – 33%
NYHA functional class III/IV – 10%
Survival: 2 year survival rate -55%
30-day mortality/morbidity rates:
operative mortality – 22%
congestive HF – 18%
bleeding – 7%
arrhythmias – 5%
renal failure – 4%
respiratory failure – 4%
infection – 4%
others – 5 %
Batista et al.1997
BRAZIL & USA
From July 1995
N=120
Hospital Angelina Caron – 50
Buffalo General Hospital – 70
Follow-up: up to 22 months for Buffalo General Hospital patients

37. PLV - Conclusions high 30 day mortality rate
uncertain medium & long term outcomes
perform in specialised centres
pre & postoperative evaluation
MRI
cardiopulmonary exercise testing

38. The future STICH trial effect of surgical ventricular restoration
survival
ventricular size and function
quality of life
exercise capacity