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LV aneurysm after acute myocardial infarction

LV aneurysm after acute myocardial infarction. 울산의대 서울아산병원 흉부외과. 주 석 중. Historical background. Baily. 1954 년 최초로 좌심실류 절제술에 성공함 . Cooley. 1958 년 최초로 심폐기하에서 좌심실류 repair 에 성공 (Plication/ Linear repair) Lillehei, Stoney, Daggett, Dor, Jatene, Cooley 등에 의해서 계속 발전됨.

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LV aneurysm after acute myocardial infarction

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  1. LV aneurysm after acute myocardial infarction 울산의대 서울아산병원 흉부외과 주 석 중

  2. Historical background • Baily. 1954년 최초로 좌심실류 절제술에 성공함. • Cooley. 1958년 최초로 심폐기하에서 좌심실류 repair에 성공 (Plication/ Linear repair) • Lillehei, Stoney, Daggett, Dor, Jatene, Cooley 등에 의해서 계속 발전됨.

  3. 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 1987;76(1):44-51

  4. ESV more accurately predicts death than low EF White HD et al. Circulation 1987;76(1):44-51

  5. Long term survivors with low EF have smaller ESV White HD et al. Circulation 1987;76(1):44-51

  6. LVESVI greater than 60ml/m2 portends poor long term prognosis

  7. Early expansion phase • 초기 심근 확장은 경색 직후부터 시작 • 경색된 심근 조직은 높은 plasticity와 creep를 보임. • T=Pr/2h 법칙에 의하여 healing으로 creep이 감소 할 때까지 infarct expansion이 계속 진행됨.

  8. Late remodeling phase • 심근 경색 발생 2-4주 후 시작하여 grannulation tissue가 나타나고, 6-8주가 되면 섬유 조직으로 대체됨. • Granulation tissue의 형성은 wound healing response의 early phase로 점차 섬유 세포 및 scar tissue로 바뀌는 과정을 밟게 된다. • 심근 발생 2 주 이내 재관류가 이루어질 경우 좌심실류의 진행이 어느 정도 예방 또는 억제될 수 있음. • Late remodeling phase 동안에 좌심실류의 확장이 이루어지는 기전에 관해서는 아직 확립된 바가 없음.

  9. 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

  10. Natural course • Recent 5YRS for medically managed LV dyskinesia : 47~70% • 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

  11. LV remodelling isa shared pathophysiology of LV aneurysm and ischemic MR Grigoni et al circulation 2001;103:1759-1764 Diodato MD et al Ann thorac surg 2004;78(3):794-799

  12. Borderzone expansion contributes to post infarction LV remodeling JACC Vol. 40, No. 6, 2002 September 18, 2002:1160–7

  13. 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

  14. Aneurysm repair causes apoptosis down regulation Group 1 - sham rats Group 2 - Aneurysm Group 3 - Anuerysm and repair group Red : Propidium iodide stainingGreen : Tunnel staining Ann Thorac Surg 2007;84:1279-87

  15. Diagnostic modality • Echocardiography • Screening method for detecting LV aneurysm • Useful for assessing MV function • Cardiac MRI

  16. Surgical Technique Plication Linear closure

  17. Guilmet procedure

  18. Mickleborough procedure

  19. Circular patch plasty

  20. Endoventricular patch plasty

  21. Surgical Ventricular Restoration

  22. 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

  23. 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

  24. AMC experience Duration : 1991 – 2008. 3월 n=60 M 52명 (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%)

  25. Preoperative echocardiogram

  26. 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

  27. Postop course

  28. Cumulative survival

  29. Case M/58 LV aneurysm 3 vessel disease

  30. Schema of Surgical Ventricular Restoration

  31. EF LV volume Preop 38 % 133 ml Immediate 25 % 111 ml postop Postop 2 36 % 103 ml Post op 3 48 % 63 ml (3 years later) Serial Echo Findings

  32. 3yrs Later after SVR 2004-09-3 2007-01-24

  33. Thank You

  34. P value SVGseq (n=37) LIMA TRA(n=23) EF(%) Preop. 53.5±12.1 55.0±12.6 NS Immdiate Postop. 54.1±9.5 56.7±13.2 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

  35. Prevention of IMR does not prevent LV remodelling after posterolateral MI J Am Coll Cardiol;43(3):377-83 The key to treating chronic infarction induced heart failure is to treat the underlying cause of the remodeling process

  36. Effects of increasing distal run-off on overall flow

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