Repair of dyskinetic or akinetic left ventricular aneurysm: results obtained with a modified linear closure

In patients with a dyskinetic or akinetic area of the left ventricle, controversy exists over who will benefit from resection. This study evaluates results achieved with a modified linear closure in 193 of 196 consecutive cases. Preoperative cases (n = 160 [83%]) were in functional class III or IV with congestive heart failure (n = 115 [60%]), angina (n = 108 [56%]), and syncope (n = 67 [35%]). The ejection fraction was 25% +/- 8%, and echocardiography showed significant mitral regurgitation in 86 (45%) patients. In patients with detailed wall motion analysis, 50 (57%) were akinetic, and 37 (43%) were dyskinetic.

Repair was completed on the beating heart to minimize ischemia and allow assessment of wall function and viability to guide resection and repair. Additional procedures included coronary artery bypass grafting (n = 175 [91%]), septoplasty (n = 24 [12%]), and arrhythmia ablation (n = 77 [40%]). Ventricular and mitral valve function were assessed by means of preoperative and/or postoperative gated acquisition scans in 171 (90%) patients and Doppler echocardiograms in 170 (88%) patients.

Hospital mortality was low (5/193 [2.6%]), although 34 (18%) patients needed perioperative intra-aortic balloon pump support. Actuarial survival at 1 and 5 years was 91% and 84%. Most late deaths were due to congestive heart failure. Seven patients required transplantation (interval, 36 +/- 32 months). As determined by multivariable analysis, factors predicting poor outcome at 5 years were preoperative mitral regurgitation of 2+ or greater, congestive heart failure, and ventricular tachycardia. Among survivors, 126 (80%) of 157 were in functional class I or II, and the average increase in ejection fraction postoperatively was 9.1% +/- 10.0%. Postoperative echocardiograms in 70 patients with significant mitral regurgitation preoperatively showed improved valve function in 40 (57%) of 70 patients.

We conclude that repair of dyskinetic or akinetic aneurysms by means of a modified linear closure plus septoplasty in selected patients can be accomplished in the beating heart with low operative mortality, provides good symptomatic relief and long-term survival, and is associated with objective evidence of improved left ventricular and mitral valve function.