Procedure

Septal reshaping

^a Division of Cardiac Surgery, University Hospital "S. Giovanni Battista", c.so Bramante 86, Turin, Italy
^b Division of Cardiac Surgery, "G D'Annunzio" University, Chieti, Italy

^* Corresponding author: ^* Tel.: +39 011 6335514; Fax: +39 011 6336130. E-mail: calafiore{at}unich.it

	Summary

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Left ventricular (LV) aneurysm is a complication of an acute myocardial infarction (AMI). Herein a new technique is described that is indicated when the postinfarctual scar involves the septum more than the free wall. The incision starts at the apex and is directed, parallel to LAD, toward the base of the heart. The septum is rebuilt using 1 or 2 U-stitches, passed from inside, to join the anterior wall to the septum. The starting point begins as high as the scar, maintaining an oblique direction toward the new apex. An oval dacron patch is then sutured from the septum (end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy and the scarred wall) up to the new apex. Thirty-day mortality is low. This procedure provides good midterm results. New York Heart Association class improved from 2.7±0.9 to 1.6±0.5 (P<0.001). Left ventricle (end-diastolic and end-systolic) volume, reduced significantly. Stroke volume normalized and ejection fraction increased even if not significantly. Mitral regurgitation reduced significantly from 2.5 to 0.6. No new mitral regurgitation developed.

Key Words: septal reshaping • left ventricular reduction • exclusion of diskinetic or akinetic areas

	Introduction

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Left ventricular (LV) aneurysm complicates an acute myocardial infarction (AMI) in 4–20% of the patients [1]. With time, the incidence of LV aneurysms decreased [2] and the anatomic presentation of the LV anteroseptal scars changed, due to diffusion of fibronolysis or primary angioplasty during AMI. Left ventricles are less dilated and the involved areas are more akinetic than dyskinetic, as the subepicardial muscle is partially salvaged.

Linear resection and direct closure, described by Cooley [3], remained the most diffuse surgical treatment for the correction of left ventricular (LV) aneurysms until the mid 1980s, when Jatene [4], Dor [5] and Guilmet [6] reported independently three different techniques for the exclusion of dyskinetic or akinetic areas following myocardial infarction in the left anterior descending (LAD) territory which maintained a more physiological shape of the LV.

Large dyskinetic or akinetic areas, which involve widely the septum, are the consequence of a proximal occlusion of the LAD. As septal branches arise from the LAD with an angle of 70 to 90°, septal necrosis goes down deep in the septum (Schematic 1 [7]). On the contrary, diagonal branches arise from the LAD with a more oblique direction (about 45°); as a consequence in the anterior free wall the necrosis extends from the LAD occlusion toward the apex as the delta of a river [8] (Schematic 2 ). As recently focused by Torrent-Guasp [9] and Buckberg [10], the aim of any technique of LV reshaping has to be not only the LV volume reduction, but also the preservation of a conical shape, in order to restore a more anatomical fiber orientation.

View larger version (53K): [in this window] [in a new window]   Schematic 1 Septal branches start from the LAD according to a 70 to 90° direction. When the LAD is occluded, septal necrosis goes down deep in the septum. (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

View larger version (41K): [in this window] [in a new window]   Schematic 2 Diagonal branches source from the LAD with a 45° oblique direction, so in the anterior free wall the necrosis extends from the point of LAD occlusion toward the apex as a small triangle. (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

Following these concepts, a new technique has been used in our institution since January 2002 [8] to obtain a conical LV shape for patients with AMI following LAD occlusion. This procedure is indicated in presence of septal dyskinetic or akinetic areas of different extension.

	Surgical technique

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All the patients have a standard monitoring, including a Swan Ganz catheter and trans-esophageal echocardiography (TEE). The ascending aorta is cannulated for arterial inflow, whereas the right atrium is cannulated for venous outflow. In case of associated mitral valve surgery, both veins are cannulated. Myocardial protection is achieved by means of intermittent antegrade warm blood cardioplegia.

The LV is opened at the apex. From there the incision (5 to 8 cm long) is directed toward the base of the heart, remaining 1 cm apart from the LAD. The LV is inspected and the point where the septal and anterior scars start identified (Video 1 ).

Click on image to view video Video 1 The apex of the left ventricle is opened and the incision is directed straight to the base of the heart, 1 cm from the LAD.

View larger version (63K): [in this window] [in a new window]   Schematic 3 The anterior wall is joined to the septum by means of an oblique linear suture with 1 or 2 polyester (Ti-cronTM2-0) U-stitches. (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

Click on image to view video Video 2 The anterior wall is joined to the septum by means of an oblique linear suture with 1 or 2 polyester (TI-CRONTM2-0) U-stitches.

View larger version (64K): [in this window] [in a new window]   Schematic 4 Stitches are made at 4 positions in the septum: at the end of the last interrupted suture (1); at the level of the new apex (2); deep in the septum at the border between the scar and the healthy posterior septum (3); and in the anterior wall, again at the limit of the scar (4). (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

Click on image to view video Video 3 Stitches are made at 4 positions in the septum: at the end of the last interrupted suture (1); at the level of the new apex (2); deep in the septum at the border between the scar and the healthy posterior septum (3); and in the anterior wall, again at the limit of the scar (4).

Click on image to view video Video 4 The four stitches are passed through an oval polyethylene terephthalate fiber (Dacron) patch and then tied.

View larger version (83K): [in this window] [in a new window]   Schematic 5 An oval polyethylene terephthalate fiber (Dacron) patch is tailored and fixed with the four stitches previously placed. (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

Click on image to view video Video 5 The patch is sutured among the septum, the anterior wall and the new apex using the four prolene stitches.

View larger version (65K): [in this window] [in a new window]   Schematic 6 The two edges of the incision, anterior and septal, are sewn together with a running 2–0 Prolene suture to assure a definitive hemostasis. (Reprinted from Ref. [15] with the permission of BC Decker).

View larger version (67K): [in this window] [in a new window]   Schematic 7 This procedure allows to create a new, more conical ventricular chamber, excluding the antero-septal scar. (Reprinted from Ref. [7] with the permission of Heart Surgery Forum).

View larger version (108K): [in this window] [in a new window]   Photo 1 The excluded cavity clots in a few weeks. (Reprinted from Ref. [8] with the permission of Elsevier Inc.).

	Results

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• From January to November 2004, 77 patients with myocardial infarction following left anterior descending (LAD) occlusion underwent septal reshaping.
  
• Mean NYHA class at the admission was 2.8±0.9. NYHA class III-IV was presented in 59.1% of the cases. In 35 cases angina was referred.
  
• Thirty-day mortality was 5.2% (one patient due to failure of a previous implanted defibrillator, two patients due to pneumonia and one due to heart failure).
  
• 2.5-year survival and possibility of being alive and in NYHA class I-II were 87.7±4.1 and 84.9±4.4, respectively (Graph 1 [7]).
  
• In the survivors NYHA class decreased from 2.7±0.9 to 1.6±0.5 (P<0.001), after a mean follow up of 16±9 months.
  
• Significant improvement of functional class was found in most of the patients (72.5%).
  
• Significant reduction of left ventricle (end-diastolic and end-systolic) volume.
  
• Normalization of stroke volume.
  
• Improvement of the ejection fraction.
  

View larger version (9K): [in this window] [in a new window]   Graph 1 Survival and possibility of being alive and in NYHA class I-II, 2.5 year after the operation.

	References

Top Summary Introduction Surgical technique Results References

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2. Cosgrove DM, Lytle BW, Taylor PC, Stewart RW, Golding LA, Mahfood S, Goormastic M, Loop FD. Ventricular aneurysm resection. Trends in surgical risk. Circulation 1989;79(6 Pt 2):I97–101.
3. Cooley DA, Collins HA, Morris GC Jr, Chapman DW. Ventricular aneurysm after myocardial infarction. Surgical excision with use of temporary cardiopulmonary bypass. JAMA 1958;167:557–560.
4. Jatene AD. Left ventricular aneurysmectomy. Resection or reconstruction. J Thorac Cardiovasc Surg 1985;89:321–331.[Medline]
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8. Calafiore AM, Di Mauro M, Di Giammarco G, Gallina S, Iacò AL, Contini M, Bivona A, Volpe S. Septal reshaping for exclusion of anteroseptal dyskinetic or akinetic areas. Ann Thorac Surg 2004;77:2115–2121.[Abstract/Free Full Text]
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15. Calafiore AM, Di Mauro M, Contini M, Vitolla G, Pelini P. Left Ventricular Volume Reduction for Dilated Cardiomyopathy. In: Franco K, Verrier E, editors. Advanced therapy in cardiac surgery, Ed. 2; BC Decker 2003.