Surgical treatment of giant left ventricular aneurysms. The intraventricular resection technique

The intraventricular resection technique for giant aneurysm of the left ventricle decreases anoxic cardiac arrest time and controls the detachment of intramural thrombus. To perform this technique, it is necessary to expose only a longitudinal segment on the anterior aspect of the aneurysm to permit a ventriculotomy parallel to the anterior descending coronary artery 4-5 cm away. In the same way, to resect a giant aneurysm of the diaphragmatic aspect, only a segment parallel to the posterior descending coronary artery needs to be exposed. Then with the clear intraventricular vision of the limit between the fibrous sac and the contracting left ventricle, the surgeon rapidly detaches the aneurysm. In any case besides the relation of this limit, the transecting line must keep away at least 4 cm from the implantation of the papillary muscle of the mitral valve, in order to leave an adequate functional chamber for the left ventricle. The early visualization of the mitral apparatus during the resection of giant aneurysm is another basic advantage of the intraventricular approach. The ventriculotomy is closed with a running suture and coronary circulation is restored. Anoxic cardiac arrest averaged 15 minutes in the five out of six cases of giant aneurysm treated with this technique. In the period July 1972-December 1973, 28 aneurysms of the left ventricle with varied associated pathology have been treated in this surgical unit, with 14% (4 cases) mortality. By contrast, no death has been registered in this severely ill group of six patients with giant left ventricular aneurysm. In cases I and VI myocardial revascularization was added. Two important aspects contribute to the excellent long term result in this group. 1. Correction of the altered geometry and consequent dysfunction of the left ventricle. 2. Correction of the functional ischemia of the contracting myocardium. The presence of giant aneurysm increases the left ventricle wall tension, including the contracting mass, and consequently the myocardial oxygen consumption.