Left Ventricular Aneurysm: Modified Linear Closure Technique

To understand the role of surgery in the treatment of patients with a ventricular aneurysm, one must first consider the criteria used to define the presence of an aneurysm. Angiographically, an aneurysm may be defined as an area of the ventricle which is demarcated from the surrounding chamber by hypokinesis, akinesis, or dyskinesis. An angiographic aneurysm^' may relate anatomically to an obvious sac of thin scar (classic pathological definition of an aneurysm) or it may correspond to a region of mixed scar and viable muscle which may be of variable thickness. In the latter case, it may not be obvious whether this region would benefit more from revascularization with the hope of recruiting hibernating myocardium and improving regional wall motion, or from resection with ventricular reconstruction. Preoperative perfusion scans and positron emission tomography have been used in attempts to separate scar tissue from viable nonfunctioning myocardium. Echocardiography and nuclear magnetic resonance may help to assess the extent of thinning in the target area. However, in these cases, we believe that the final decision with regards to appropriate intervention can best be made at the time of surgery. With direct examination of the heart, if the area in question is scarred and significantly thinned, resection is indicated. For aneurysm repair, we prefer a modified linear closure technique.' This approach is applicable for all types of aneurysms (broad-based or narrow-necked, true or false). Advantages of this technique are that it is relatively simple, it provides reproducible results, and it can be adapted for a variety of intraoperative situations (calcified or noncalcified). The entire repair can be safely performed in the decompressed beating heart. This approach decreases ischemic time in patients who often have significant compromise of ventricular function and diffuse triple vessel disease. In our opinion, the only situations in which a more complex type of endoaneurysmorrhaphy repair technique may be advantageous' is in cases of acute infarction where friable tissues may make a linear closure difficult or impossible to perform.