A. A. Assi1, S. F. Bolling1, H. J. Patel1, M. Deeb1, M. A. Romano1, J. W. Haft1, R. L. Prager1, F. D. Pagani1, P. C. Tang1 1University Of Michigan,Department Of Cardiac Surgery,Ann Arbor, MI, USA
Introduction:
This study investigates the long term outcomes and predictors of mortality for left ventricular (LV) aneurysmectomy.
Methods:
From 1992 to 2017, there were 109 patients who underwent a LV aneurysmectomy procedure. Long term survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique and follow up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival.
Results:
Median age was 63 (IQR=19) years, with 25 (22.9%) females. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Location of the aneurysm was antero-apical in 92 (84%) and posterior in 17 (16%). Average preoperative left ventricular diastolic dimension (LVIDD) was 6.7+2.7cm. Operative technique included primary closure without a patch in 58 (53%) and closure with patch in 51 (47%) patients. Concomitant surgeries included mitral valve (MV) repair (n=40, 37%), MV replacement (n=5, 5%), tricuspid valve (TV) repair (n=4, 4%), aortic valve (AV) replacement (n=3, 3%), coronary bypass grafting (n=76, 70%; 1.6+1.3 grafts) and VSD closure (n=5, 5%). Redo-sternotomies were performed in 12 (11%) patients. Median echocardiography follow up was 2.9 yrs (IQR=9.0), and was obtained in 59 (54%) patients. LVEF improved from 28+13% to 33+16% (P=0.011). There was a higher incidence of moderate to severe right ventricular (RV) function at follow-up (12% preoperatively versus 38% at follow-up; P=0.021) and higher incidence in severe TV regurgitation in patents who did not undergo repair (8.9% versus 22.2% respectively; P=0.004). Median echo follow up of MV repair was 3.6 (IQR=9.5) yrs. MV repair led to sustained improvements in MR (P=0.001) where only 2 (5%) experienced recurrent moderate-severe MR. For patients who did not undergo a MV procedure, there was no difference in preop and follow up MR severity (P=0.586). Median patient follow up was 7.1 yrs (IQR=8.5). Overall 5, 10, and 15 year survival were 71.9%, 48.1% and 26.2% respectively (Fig. 1). A multivariable analysis identified concomitant TV repair (P=0.001), increasing preoperative TV regurgitation (P=0.037), and concomitant AV replacement (P=0.086) as independent predictors of mortality.
Conclusion:
Long term survival following LV aneurysmectomy is adversely influenced by RV function. While sustained improvement in LVEF and decreased MR following MV repair can be expected, RV function continues to decline accompanied by worsening tricuspid regurgitation. Close surveillance and aggressive medical management of RV failure is warranted in this patient population.