Left Ventricular Reconstruction for Postinfarction Left Ventricular Aneurysm: Review of Surgical Techniques

Abstract

Different surgical techniques, each with its own advantages and disadvantages, have been used to reverse adverse left ventricular remodeling due to postinfarction left ventricular aneurysm. The most appropriate surgical technique depends on the location and size of the aneurysm and the scarred tissue, the patient's preoperative characteristics, and surgeon preference. This review covers the reconstructive surgical techniques for postinfarction left ventricular aneurysm.

Keywords: Cardiac surgical procedures/methods; heart aneurysm/diagnosis/etiology/pathology/surgery; heart ventricles/pathology/surgery; myocardial infarction/complications/physiopathology; risk factors; suture techniques; ventricular dysfunction, left/etiology; ventricular function, left/drug effects/physiology.

Fig. 1.

Diagrams show the Cooley technique (“linear” or “sandwich” repair). A) The left ventricular (LV) cavity is reduced in size. B) The lateral and medial (septal) walls are sutured together at a point where they normally would be separated by several centimeters, resulting in nonanatomic geometry. Reprinted with permission from Mukaddirov M, Demaria RG, Perrault LP, Frapier JM, Albat B. Reconstructive surgery of postinfarction left ventricular aneurysms: techniques and unsolved problems. Eur J Cardiothorac Surg 2008;34(2):256–61.

Fig. 2.

Diagrams show the Stoney technique, an early attempt to increase the curvature of the left ventricle in an aneurysmal area. A) The lateral wall of the myocardium is brought toward the ventricular septum at the junction between viable muscle tissue and scar. The lateral edge of the myocardium is sutured to the interventricular septum, in a continuous fashion, in the border zone between the viable and scarred tissue. Then, polytetrafluoroethylene strips are used to reinforce the left ventricular margin, and stitches are brought outside through the septum to the anterior wall. B) The repair is completed by overlapping the lateral healthy myocardial wall of the left ventricle with the scar tissue. Reprinted with permission from Stoney WS, Alford WC Jr, Burrus GR, Thomas CS Jr. Repair of anteroseptal ventricular aneurysm. Ann Thorac Surg 1973;15(4):394–404.

Fig. 3.

Diagrams show a transverse section of the left ventricle and the curvature of the ventricular wall in A) a normal heart, B) an ischemic heart with an aneurysm, C) a heart with an aneurysm repaired by eversion, and D) a heart with an aneurysm repaired by inversion of a ventriculotomy. Whereas the eversion technique reduces the curvature of the wall, the inversion technique increases the curvature, thus promoting increased cardiac function. Reprinted from Hutchins GM, Brawley RK. The influence of cardiac geometry on the results of ventricular aneurysm repair. Am J Pathol 1980;99(1):221–30, with permission from Elsevier.

Fig. 4.

Diagrams show the Dor technique. A) After the aneurysm is opened, the endocardial scar tissue at the level of the interventricular septum is undermined and then B) resected. C) The junction between scar tissue and normal myocardium is cryoablated to prevent ventricular tachycardia. D) A purse-string suture is placed at the base of the aneurysm, at the junction between the endocardial scar and the normal myocardium. The suture, when tied with the proper tension, restores the normal orientation of the muscle fibers. E) An endocardial patch is anchored at the level of the circumferential suture to complete the closure of the ventricle. Reprinted from Dor V. Surgical management of left ventricular aneurysms by the endoventricular circular patch plasty technique. Oper Techn Cardiac Thorac Surg 1997;2(2):139–50, with permission from Elsevier.

Fig. 5.

Diagrams show the McCarthy technique. A) The aneurysm is opened 2 cm lateral to the left anterior descending coronary artery. B) A purse-string suture is placed into the scarred tissue, around the base of the aneurysm, then tied off. To ensure the resulting opening is <3 cm wide, a second purse-string suture is placed 4 mm above the first. C) The second purse-string suture has been tied and closure begun. D) To complete closure, interrupted mattress sutures are passed through Teflon felt strips on either side of the opening at the level of the purse-string suture, and the opening is reinforced with a continuous 3-0 polypropylene suture. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2000–2017. All rights reserved. Figures 6B and 6C, specifically, reprinted from Caldeira C, McCarthy PM. A simple method of left ventricular reconstruction without patch for ischemic cardiomyopathy. Ann Thorac Surg 2001;72(6):2148–9.