Surgical Treatment of Left Ventricular Aneurysm Combined with Ischemic Mitral Regurgitation Using a Modified Technique

Background. Ischemic mitral regurgitation (IMR) is the second most common cause of mitral regurgitation (MR). IMR occurs in patients with myocardial infarction due to a rupture of the subvalvular apparatus. Pathological remodel-ing, dilatation and dysfunction of the left ventricle (LV) play a significant role in the development of IMR. The presence of a postinfarction LV aneurysm can lead to the development of MR due to dysfunction, relative and true shortening of the papillary muscles. There are various methods of surgical correction of IMR. The aim. To show the effectiveness of surgical treatment of left ventricular aneurysm combined with ischemic mitral regurgitation using a modified technique. Materials and methods. From January 2011 to December 2019, 20 patients with IMR combined with LV aneurysm underwent surgical intervention using a modified technique at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine. According to this technique, access to the mitral valve was performed through the left ventricle. The mean age of the patients was 61.2 ± 10.1 years. Among patients with IMR, the majority were men (60.0%). The overwhelming majority of patients (80.0%) had the history of hypertension. Diabetes mellitus was detected in 35.0% of patients. Mitral ring dilatation was observed in 25.0% (5) of the cases, papillary muscle displacement in 40.0% (8), chords rupture in 15.0% (3), papillary muscle infarction in 20.0% (4) of the cases. All the patients had reduced LV ejection fraction with a mean value of 34.5 ± 7.8%. Results. Aortic cross-clamp time through ventricular access was 112.9 ± 18.7 minutes. The duration of mechanical ventilation was 19.1 ± 20.6 hours. The length of stay of patients in the ICU was 99.2 ± 43.5 hours. There were no signs of acute heart failure in the early postoperative period in one in five patients (20.0%). The rate of degree III heart failure after intervention using the modified technique was 20.0% (4). The study of the incidence of cardiac arrhythmias after combined intervention showed that 85.0% (17) of patients operated using the modified technique had no cardiac arrhythmias. Conclusions. In patients who underwent surgery using the modified technique, the mortality rate was 5.0%. This is 1.6-2.8 times less than that in patients undergoing conventional operation. Postoperative occurrence of arrhythmias is much less common than that described in the literature.

Prognostic implications of left ventricular torsion by feature-tracking cardiac magnetic resonance in patients with ST-elevation myocardial infarction

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the National Key Research and Development Program of China OnBehalf Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University Background The prognostic implications of left ventricular (LV) torsion on the long-term prognosis of patients with acute ST-elevation myocardial infarction (STEMI) is not clear. Methods We analyzed Cardiac Magnetic Resonance (CMR) images and followed up 420 first STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). These patients received timely primary percutaneous coronary intervention (PCI) within 12h and CMR examination within 1 week (median,5 days; range, 2-7 days) after infarction. Besides, CMR images of 40 normal people were enrolled as the control group. LV torsion, torsion rate and other conventional CMR indexes were measured. Ultrasound cardiogram examinations were performed in the acute phase and 1 year post-STEMI to assess LV remodeling (≥ 20% increase in LV end-diastolic volume). Primary end point was composite major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, re-hospitalization for heart failure and stroke. Secondary end points were the formation of LV aneurysm/thrombus in hospital as well as LV remodeling at 1 year post-STEMI. Results During follow-up (median: 52 months, inter-quartile range: 29–78 months), 80 patients developed MACCEs. Compared with normal people, patients with STEMI had more decreased LV torsion (P < 0.001) and torsion rate (P = 0.033). Patients who experienced MACCEs had more impaired LV torsion (P < 0.001) and torsion rate (P < 0.001) than those who didn’t. LV torsion ≤ 0.876 deg/cm in the acute phase of STEMI was an independent predictive factor of MACCE (P = 0.001) and LV remodeling (P = 0.001). Patients with impaired LV torsion were more likely to experience MACCEs (P < 0.001). The impairment of LV torsion was also associated with the higher incidence of LV aneurysm (P < 0.001) and thrombus (P = 0.006). The addition of LV torsion to a risk model comprising LV ejection fraction (LVEF), infarct size (IS), and microvascular obstruction (MVO) led to a net reclassification improvement (continuous NRI 0.499 [95% CI, 0.261–0.737]; P < 0.001). Hypertension (P = 0.047), tobacco use (P = 0.005), worse TIMI flow post-PCI (P < 0.001), more extensive IS (P < 0.001) / MVO size (P = 0.002) were associated with the impairment of LV torsion. Conclusions Compared with normal people, patients with STEMI had more decreased LV torsion and torsion rate. LV torsion ≤ 0.876 deg/cm in the acute phase was an independent predictive factor of MACCE and LV remodeling. The addition of LV torsion to a risk model comprising LVEF, LV-IS and LV-MVO significantly improved risk stratification of patients with STEMI .

Two-dimensional echocardiography compared to cardiac computed tomography for assessment of left ventricular volume and function in patients with anteroapical aneurysm

Funding Acknowledgements Type of funding sources: None. Background. Two-dimensional (2D) echocardiography is widely accepted method for the assessment of left ventricular (LV) morphology and function after myocardial infarction and for initial preoperative evaluation of patients planned for surgical ventricular repair (SVR). Magnetic resonance imaging and cardiac computer tomography (CT) provide more accurate measurements, but not always available. Purpose. The aim of this study was to compare 2D-echocardiography and CT for preoperative assessment of patients with LV aneurysm in order to optimize the perioperative management in SVR. Methods. Patients (n = 179, mean age 62.6 ± 11 years, 23.5% women) with LV anteroapical aneurysm due to myocardial infarction were examined by echocardiography and CT before SVR. LV end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) obtained by two methods were compared pairwise. Prognostic role for the prediction of all-cause death was assessed for preoperative parameters in multivariate Cox regression model adjusted for patient age, sex, NYHA class, diabetes mellitus, renal failure, atrial fibrillation and arterial hypertension. Results. There was a strong correlation for preoperative LVEDV and LVESV measured by echocardiography and CT (r = 0.85, r = 0.87, p < 0.0001), however volumes obtained by echocardiography were smaller compared to those by CT (Table) with higher difference in patients with more dilated LV, as demonstrated by Bland-Altman analysis (Fig.). No significant difference in mean preoperative EF was observed with moderate correlation between two methods (r = 0.67, p < 0.0001). In total 68 patients died during median follow up of 5.3 years (IQR: 1.7-8.7 years) after SVR. Comparable predictive value was demonstrated for LVEDV measured by CT and echocardiography (for 10 ml increase HR = 1.04, p = 0.004 and HR = 1.06, p = 0.0001), as well as for LVESV (for 10 ml increase HR = 1.04, p = 0.001 and HR = 1.07, p = 0.0001) and for EF (for 5% increase HR = 0.83, p = 0.004 and HR = 0.81, p = 0.004). Conclusion. In patients with LV aneurysm 2D-echocardiography may be used for the assessment of LV volumes and function and have similar prognostic role compared to CT in patients evaluated for SVR. Underestimation of LV volumes by echocardiography must be considered, especially in patients with more dilated LV. Comparison of CT and echocardiography Parameter CT Echo Mean difference p-value LVEDV, ml LVESV, ml EF, % 289 ± 104 198 ± 97 34 ± 12 222 ± 81 149 ± 67 35 ± 9 67 ± 56 49 ± 51 -0.9 ± 9.2 <0.0001 <0.0001 0.215 Abstract Figure. Bland-Altman plots for LVEDV and LVESV

SURGICAL MANAGEMENT OF LEFT VENTRICULAR ANEURYSM AS A COMPLICATION OF ACUTE MYOCARDIAL INFARCTION - A SINGLE SURGEON EXPERIENCE

Left ventricular aneurysm is a localized area of the myocardium, with abnormal outward bulging and deformation during systole and diastole, which may be an akinetic, dyskinetic hypokinetic segment. It is due to the weakening of the muscle wall. The aim of this study is the assessment of the Left Ventricular aneurysm, its clinical presentation, Repair technique, and surgical outcome of patients presented with Acute Myocardial infarction with Ventricular wall complications. A retrospective study of the case scenarios that have undergone LV aneurysm repair in a tertiary care hospital facility over four years (2015-2019) after being diagnosed with Acute and evolved Myocardial infarction, which has been rehabilitated by medical management and then referred from cardiology. The Cases with aneurysm were diagnosed by 2d- echocardiography, examined for window period, taken up for surgery, which is re-vascularisation and surgical ventricular remodeling. Of the 6 cases operated, the results were as follows. The mean age of presentation is early for patients with co-morbidities like diabetes and hypertension. Female preponderance is seen. Habitual alcohol consumption causes an early presentation of symptoms. Severe LV dysfunction due to occlusion of the Left coronary artery causes this aneurysm. The most frequent site of aneurysm is the anterior wall with an apex. Apex or Distal anterior wall involvement is repaired by Dor or Linear repair. A septal aneurysm is repaired by septal exclusion by linear Dacron. To conclude, acute MI due to Single or Triple vessel disease can lead to LV aneurysm, which can be Akinetic or Dyskinetic segment.LV Aneurysm as a complication can have a varied presentation, including an Anterior wall, Apex, Apex, and variable extent of the septum and posterior wall, with varied ventricular function with organic valvular MR or Functional MR. Patients with Hypertension and Habitual alcohol consumption have an early age of presentation

Prognostic role of left ventricular diastolic function assessed by speckle tracking echocardiography in patients after surgical ventricular repair

Background Assessment of left ventricular (LV) diastolic function brings important prognostic information for patients with heart failure and could be evaluated by speckle tracking echocardiography (STE). Less known about its role in patients planned for surgical ventricular repair due to LV aneurysm. Purpose The aim of this study was to evaluate the prognostic role of STE parameters of LV diastolic function for prediction of all-cause mortality in patients after surgical ventricular repair. Methods We retrospectively evaluated data of 163 consecutive pts (mean age 62.3±11.5 years, 74.8% males) with anteroapical LV aneurysm who underwent surgical ventricular repair combined with coronary artery bypass surgery (71.8%) Prognostic role for prediction of all-cause mortality was assessed for various STE parameters, including left atrial strain (LAS) measured as peak reservoir strain and for the ratio of early to late global longitudinal strain rate (GLSRe/GLSRa). Results During a median follow-up of 4.7 years (IQR: 1.6–8.9 years) there were 65 deaths, 5 year survival rate was 73.8 (95% CI 67–79%). Baseline ejection fraction, end-diastolic and end-systolic volumes of LV did not differ between pts who died and survived at 5 year after the surgery, whereas LAS was significantly higher and GLSRe/GLSRa was significantly lower in survivors. Cox proportional hazard model adjusted to demographic and clinical variables demonstrated that LAS and GLSRe/GLSRa were independent predictors of all-cause death, with HR of 0.79 (95% CI 0.66–0.95, p=0.012) for each 5% increase of LAS and HR of 1.24 (95% CI 1.1–1.4, p=0.001) for each 0.5 increase of GLSRe/GLSRa. Moreover, GLSRe/GLSRa remained an independent predictor after additional adjustment for LV end-systolic volume, sphericity index and presence of mitral insufficiency of grade 2 and higher. A significant difference in median survival time was demonstrated according to the following cut-offs: LAS ≥16.7% (12.1 vs. 6.4 years, p=0.01), GLSRe/GLSRa ratio ≥2.3 (3.3 years vs. 10.2 years, p=0.0005) (Figure). The classification and regression tree analysis with the application of all two-dimensional, Doppler and various speckle-tracking echocardiographic parameters revealed that GLSRe/GLSRa and LAS were the most important echocardiographic variables for risk stratification for 5-year mortality. Conclusion This study demonstrates that STE parameters of LV diastolic function are important predictors of all-cause mortality after surgical ventricular repair due to anteroapical aneurysm of LV and could be used in the preoperative decision-making process. Funding Acknowledgement Type of funding source: None

Non-ischaemic intramyocardial dissection following total arch replacement

Intramyocardial dissection (ID) is a rare left ventricular (LV) disorder characterized by myocardial fibre dissection and neocavitation. In this study, we present a rare case of a 66-year-old woman who had a history of sarcoidosis with non-ischaemic ID following total arch replacement. ID developed suddenly in the free wall of the LV and expanded rapidly to form an LV aneurysm. We successfully performed LV reconstructive surgery to prevent ID rupture.

497 Multimodality imaging of an evergreen conundrum: true or false aneurysm of the left ventricle?

In case of transmural necrosis following STEMI, the myocardial wall may develop a true or false aneurysm. While the former usually has a benign course, the latter has a propensity to rupture leading to an ominous prognosis. We report the case of a patient with a recent inferior STEMI complicated with LV aneurysm of the inferior wall, initially diagnosed as a false aneurysm. We describe the case of a 77-year-old man affected by hypertension, diabetes and AF. Two months before he experienced an inferior STEMI treated with late (>12 hours from symptoms onset) pPCI and implantation of a DES on the RCA and the postero-lateral branch. TTE showed a mildly reduced LV systolic function (EF 50%) due to akinesia of the inferior wall. The patient presented to the ED for recurrent syncopes at rest. Vital signs were unremarkable. Troponin and electrolytes were within normal range. ECG showed a normofrequent sinus rhythm and Q waves with persistent ST elevation in the inferior leads. TTE showed a suspected rupture of the inferior wall in the middle segment between the posterolateral papillary muscle and the mitral annulus. The rupture seemed to be contained by the pericardium so as to create a huge cavity communicating with the LV through an apparently small neck and refurnished with turbolent blood during the cardiac cycle. In the suspicion of a pseudoaneurysm ( an urgent cardiac CT was performed. CT showed an extraventricular cavity apparently contained by the pericardium with a narrow neck and a pericardial effusion of a high density liquid. A diagnosis of post-infarction pseudoaneurysm was made. The day after the patient was stable but TTE showed a mild increase of the size of the "pseudoaneurysm", hence the Heart Team referred the patient to the cardiac surgery department for an urgent repair. In the surgical room TOE displayed the large cavity rising from the inferior wall of the LV and the communication thorugh a large neck. The intraoperatory finding was, unexpectedly, a true aneurysm of the inferior wall. The redundant aneurysm was excised and the defect was succesfully closed with a bovine pericardium patch. No periprocedural complication was recorded and the postoperatory period was uneventful. The present case strikingly shows how a mechanical complication may develop in spite of myocardial revascularization. The high level of suspicion led to a strong effort to achieve a definite diagnosis. Multimodality imaging plays a pivotal role and is warranted since the initial evaluation with TTE may be inconclusive. CT has a high diagnostic yield but false positives may happen. MRI could have been more specific in our case, but the clinical evolution and the CT images led us to be confident in referring the patient to an urgent cardiac surgery. In conclusion, the non invasive differential diagnosis between true and false aneurysm still remains a modern challenge. Abstract 497 Figure. Multimodality imaging of a LV aneurysm

P1257 Additional value of echocardiography in critical patient: a quick and effective tool to improve diagnosis and treatment

A 72 year-old woman with Hashimoto thyroiditis in replacement therapy and no known CV risk factors was admitted to the emergency department because of worsening asthenia, nausea, vomiting and fever unresponsive to antibiotic therapy. Two weeks before the admission, she had a syncopal episode preceded by intense chest pain for which she hadn’t seek medical help. At admission, the patient was unconscious and hemodynamically unstable with signs of shock (BP 80/50 mmHg, HR 120 bpm, lactate 6.11 mmol/L). She was promptly intubated and mechanically ventilated, and fluids and vasopressor treatment was administered. Lab tests showed moderate anaemia (haemoglobin 8.3 mg/dl), mild neutrophilia, elevated inflammatory markers (C-reactive protein 87 mg/dl) and troponin I (679 ng/L). An ECG showed sinus tachycardia and inferior Q waves. A thoraco-abdominal CT excluded pulmonary embolism and showed a suspect acute cholecystitis, suggesting a septic shock. However, a focused transthoracic echocardiogram in the emergency room showed a dilated and non-collapsing inferior vena cava, a severe mitral regurgitation and a very large rounded structure suggestive of left ventricle (LV) aneurysm/pseudoaneurysm, but it was inconclusive due to the poor acoustic window of the patient. The review of CT images also did not allow to make a clear diagnosis of LV aneurysm vs pseudoaneurysm. The patient was transferred in the ICU for further investigation; inotropes, vasopressors, blood transfusion and antibiotics were administered. A complete transthoracic echocardiogram (TTE) was performed to clarify the diagnosis between septic and cardiogenic shock. TTE revealed a large aneurysm (55x40 mm) of the inferior interventricular septum and inferior basal and mid LV segments, with a ventricular septal defect (VSD) with left-right shunt, a severe ischaemic mitral regurgitation and a severely dilated and dysfunctional right ventricle. Due to the suboptimal quality of TTE, an urgent transoesophageal examination (TEE) was done which revealed mobile masses attached on the tricuspid and the aortic valves suggestive of vegetations and confirmed the VSD at the level of a large inferoseptal LV aneurysm and severe ischaemic mitral regurgitation with no signs of papillary muscle or chordal rupture (Figure). Coronary angiography was performed, showing proximal occlusion of right coronary artery (likely embolic) with initial collateral circulation. Blood cultures were positive. The patient underwent cardiac surgery, which confirmed the diagnosis of endocarditis associated with VSD and LV aneurysm. The postoperative course was complicated by multiple organ dysfunction syndrome and death after 19 days of intensive care. Learning point in challenging cases with unclear diagnosis of septic versus cardiogenic shock, both TTE and TOE play a pivotal role showing a series of findings that can help clarifying the diagnosis and guide patient treatment in emergency settings. Abstract P1257 Figure

1036 Prognostic role of left ventricle longitudinal strain for the prediction of survival after surgical ventricular repair

Background Surgical ventricular repair (SVR) in patients with ischemic cardiomyopathy is aimed to reshape left ventricle (LV) and reduce its volume in order to improve prognosis and quality of life. There are controversies regarding benefit of SVR, especially in patients with severely enlarged LV. Purpose Our purpose was to investigate prognostic value of LV longitudinal strain for survival and for the improvement of LV function after SVR in patients with anteroapical LV aneurysm. Methods 218 pts (2005-2018, mean age 63.6 ± 11.2y, 73.9% males) with anteroapical LV aneurysm due to myocardial infarction underwent SVR combined with coronary bypass grafting (77.5%), mitral valve repair (18.3%) and LV thrombectomy (22.0%). Preoperative strain analysis was done retrospectively for 146 patients. Prognostic value of strain was tested in pts according to the LV end systolic volume index (LVESVI) with the cut-off value of 60ml/m². In 17 pts 1-year follow-up with strain quantification was done. Results During a median follow-up of 3.9 years (IQR: 1.0-6.8 years) there were 68 deaths and 1 patient was lost to follow-up. 30-days survival rate was 93.5% (95%CI: 90.3; 96.9%), 5 year survival – 72.5% (95%CI: 66.0-79.6%). Pts who died were significantly older, with higher proportion of diabetes (DM), peripheral artery disease, renal failure (RF) and atrial fibrillation (AF). Baseline ejection fraction (EF) and global longitudinal strain (GLS) did not differ significantly. Whereas basal longitudinal strain (BLS) was higher (more negative) in pts who survived (-11.4 ± 3% vs. -10.1 ± 4%, p = 0.027). Risk stratification by tertiles revealed that BLS was a significant predictor of survival. The risk of dying was 3 times higher for pts in the lowest tertile compared to those in the highest tertile (HR: 2.94, 95%CI:1.37-6.25, p = 0.013). When adjusted to age, AF, DM, RF, and previous heart surgery, BLS was an independent predictor of death (HR = 1.14, 95%CI:1.03;1.26, p = 0.032). At 1-year follow-up (12.7 ± 5.1 months) there was significant decrease of LV end-diastolic and end-systolic volume indices, from 102.8 ± 24.1 ml/m² to 77.9 ± 24 ml/m² (p < 0.001) and from 67 ± 23.2 ml/m² to 44.3 ± 7.6 ml/m² (p < 0.001), correspondingly, and increase of EF from 36.3 ± 9.4% to 44.4 ± 7.6% (p = 0.001). The mean systolic GLS improved from -6.6 ± 2.6% to -8.7 ± 3.2%, p = 0.008. Among 81 segments with baseline hypokinesia, 44 segments (54.3%) recovered their contractility, 36 segments (44.4%) remained hypokinetic and 1 segment deteriorated to akinesia. Mean systolic strain of segments which showed recovery was -6.6 ± 4.0% compared to -3.8 ± 4.5% with no improvement (p = 0.005). Cut-off value of systolic strain for prediction of recovery was -5.4 % (AUC = 0.69, p = 0.004; PPV = 0.73, NPV = 0.61). Conclusion Our study demonstrates that BLS is an independent predictor of survival after SVR in patients with LV anteroapical aneurysm. Furthermore, higher systolic strain predicts recovery of LV regional function at 1-year after SVR.