LV aneurysm after acute myocardial infarction

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LV aneurysm after acute myocardial infarction
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? ? ?
2
Historical background

• Baily. 1954? ??? ???? ???? ???.
• Cooley. 1958? ??? ?????? ???? repair? ??
  (Plication/ Linear repair)
• Lillehei, Stoney, Daggett, Dor, Jatene, Cooley ??
  ??? ?? ???.

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Direct correlation between LV volume and survival
Figure 1. Relative risk for death after
transmural myocardial Infarction correlates with
end systolic volume. White HD et al.
Circulation 198776(1)44-51
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ESV more accurately predicts death than low EF
White HD et al. Circulation 198776(1)44-51
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Long term survivors with low EF have smaller ESV
White HD et al. Circulation 198776(1)44-51
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LVESVI greater than 60ml/m2 portends poor long
term prognosis
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Early expansion phase

• ?? ?? ??? ?? ???? ??
• ??? ?? ??? ?? plasticity? creep? ??.
• TPr/2h ??? ??? healing?? creep? ?? ? ???
  infarct expansion? ?? ???.

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Late remodeling phase

• ?? ?? ?? 2-4? ? ???? grannulation tissue? ????,
  6-8?? ?? ?? ???? ???.
• Granulation tissue? ??? wound healing response?
  early phase? ?? ?? ?? ? scar tissue? ??? ??? ??
  ??.
• ?? ?? 2 ? ?? ???? ???? ?? ????? ??? ?? ?? ?? ??
  ??? ? ??.
• Late remodeling phase ??? ????? ??? ????? ???
  ???? ?? ??? ?? ??.

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Factors contributing to LV aneurysm formation

• Preserved contractility of surrounding myocardium
• Transmural infarction
• Lack of collateral circulation
• Lack of reperfusion
• Elevated wall stress
• Hypertension
• Ventricular dilatation
• Wall thinning

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Natural course

• Recent 5YRS for medically managed LV dyskinesia
  4770
• Cause of death
• Arrhythmia 44 Heart failure 33
• Recurrent MI 11 Non cardiac cause 22
• Factors influencing survival of LV dyskinesia
• Age HF score Coronary disease severity
• Angina duration Prior infarction MR
• Function of residual ventricle

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LV remodelling is a shared pathophysiology of LV
aneurysm and ischemic MR
Grigoni et al circulation 20011031759-1764
Diodato MD et al Ann thorac surg
200478(3)794-799
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Borderzone expansion contributes to post
infarction LV remodeling
JACC Vol. 40, No. 6, 2002 September 18,
200211607
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LV remodeling involves apoptosis of normally
perfused peri-infarct tissue

• Pathologic condition of postinfarction LV
  remodeling cause changes in cellular and
  biochemical levels
• Increased appearance of vacuolated cells in
  periinfarct zone indicating apoptotic changes
• Upregulation of caspase-3 activity
• - key mediator of apoptosis in mammalian cells

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Aneurysm repair causes apoptosis down regulation
Group 1 - sham rats Group 2 - Aneurysm Group 3 -
Anuerysm and repair group
Red Propidium iodide staining Green Tunnel
staining
Ann Thorac Surg 2007841279-87
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Diagnostic modality

• Echocardiography
• Screening method for detecting LV aneurysm
• Useful for assessing MV function
• Cardiac MRI

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Surgical Technique

• Plication
• Linear closure

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Guilmet procedure
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Mickleborough procedure
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Circular patch plasty
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Endoventricular patch plasty
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Surgical Ventricular Restoration
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Outcomes and prognosis

• Low early mortality
• 2-13
• Acceptable 5 and 10 year mortality
• 5 year survival 58-80
• 10 year survival 30 ( better than medical Tx)
• Most patients experience increased LV performance
  
• LVEF? Pulm pressure? LV volume? MV O2 demand ?
  Exercise tolerance ?
• Scientific evidence to be collected through the
  STICH trial

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The STICH trial (Surgical Treatment for Ischemic
Heart Failure)

• Target registry 2800 patients with 90
  participating centers
• Objectives to seek best treatment for
• coronary disease and heart failure
• (Inclusive of SVR)
• Groups
• Medical therapy alone
• Medical therapy CABG
• Medical therapy CABG and SVR

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AMC experience

• Duration 1991 2008. 3? n60
• M 52? (85) Mean age 60.6
• Preop NYHA functional class
• I 1
• II 12
• III 35
• IV 13
• 78 of the patients were in functional class III
  or IV
• Associated conditions
• 3VD 50 (82)
• Preop IABP 4 (7)

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Preoperative echocardiogram
Parameter Value
EF() 31.010.0
LVIDs (mm) 48.510.1
LVIDd (mm) 61.18.5
LVESV (ml) 124.357.4
LVEDV (ml) 173.567.1
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Surgical Method

• Surgery Value
• Pication
  3
• Linear repair
  28
• Endoventricular patch 30
• Concom. Proced .
• CABG
  59 (96.7)
• Ring
  6
• Double orifice
  4
• Pap m. imbrication
  3
• Posterior annuloplasty 5

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Postop course
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Cumulative survival
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Case
M/58 LV aneurysm 3 vessel disease
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Schema of Surgical Ventricular Restoration
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Serial Echo Findings
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3yrs Later after SVR
2004-09-3
2007-01-24
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Thank You
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(No Transcript)
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P value
LIMA TRA(n23)
SVGseq (n37)
EF() Preop.
53.512.1 55.012.6
NS Immdiate Postop. 54.19.5
56.713.2 NS CT
finding Non-visualization
0(0) 0(0)
NS Faint() LAD
1(2.7) 3(15.0) NS
V1 0(0)
1(5.0) NS
V2 0(0)
0(0) NS
V3 1(7.7)
0(0) NS
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Prevention of IMR does not prevent LV remodelling
after posterolateral MI
J Am Coll Cardiol43(3)377-83
The key to treating chronic infarction induced
heart failure is to treat the underlying cause
of the remodeling process
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Effects of increasing distal run-off on overall
flow