LV aneurysm after acute myocardial infarction 울산의대 서울아산병원 흉부외과 주 석...
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Transcript of LV aneurysm after acute myocardial infarction 울산의대 서울아산병원 흉부외과 주 석...
Historical background
• Baily. 1954 년 최초로 좌심실류 절제술에
성공함 .
• Cooley. 1958 년 최초로 심폐기하에서
좌심실류 repair 에 성공 (Plication/
Linear repair)
• Lillehei, Stoney, Daggett, Dor, Jatene,
Cooley 등에 의해서 계속 발전됨 .
Direct correlation between LV volume and survival
Figure 1. Relative risk for death after transmural myocardial Infarction correlates
with end systolic volume. White HD et al. Circulation 1987;76(1):44-
51
Early expansion phase
• 초기 심근 확장은 경색 직후부터 시작
• 경색된 심근 조직은 높은 plasticity 와
creep 를 보임 .
• T=Pr/2h 법칙에 의하여 healing 으로
creep 이 감소 할 때까지 infarct
expansion 이 계속 진행됨 .
Late remodeling phase
• 심근 경색 발생 2-4 주 후 시작하여 grannulation
tissue 가 나타나고 , 6-8 주가 되면 섬유 조직으로 대체됨 .
• Granulation tissue 의 형성은 wound healing
response 의 early phase 로 점차 섬유 세포 및 scar
tissue 로 바뀌는 과정을 밟게 된다 .
• 심근 발생 2 주 이내 재관류가 이루어질 경우 좌심실류의 진행이 어느 정도 예방 또는 억제될 수 있음 .
• Late remodeling phase 동안에 좌심실류의 확장이 이루어지는 기전에 관해서는 아직 확립된 바가 없음 .
Factors contributing to LV aneurysm formation
• Preserved contractility of surrounding
myocardium
• Transmural infarction
• Lack of collateral circulation
• Lack of reperfusion
• Elevated wall stress
• Hypertension
• Ventricular dilatation
• Wall thinning
Natural course• Recent 5YRS for medically managed LV
dyskinesia : 47~70%
• Cause of death – Arrhythmia 44% : Heart failure 33%
– Recurrent MI 11% : Non cardiac cause 22%
• Factors influencing survival of LV dyskinesia– Age : HF score : Coronary disease severity
– Angina duration : Prior infarction : MR
– Function of residual ventricle
LV remodelling is a shared pathophysiology of LV aneurysm and
ischemic MR
Grigoni et al circulation 2001;103:1759-1764Diodato MD et al Ann thorac surg 2004;78(3):794-799
Borderzone expansion contributes to post infarction LV remodeling
JACC Vol. 40, No. 6, 2002 September 18, 2002:1160–7
LV remodeling involves apoptosis of normally perfused peri-infarct tissue
• Pathologic condition of postinfarction LV
remodeling cause changes in cellular and
biochemical levels
• Increased appearance of vacuolated cells in
periinfarct zone indicating apoptotic changes
• Upregulation of caspase-3 activity
- key mediator of apoptosis in mammalian cells
Aneurysm repair causes apoptosis down regulation
Group 1 - sham ratsGroup 2 - Aneurysm Group 3 - Anuerysm and repair group
Red : Propidium iodide staining Green : Tunnel staining Ann Thorac Surg 2007;84:1279-87
Diagnostic modality
• Echocardiography
– Screening method for detecting LV aneurysm
– Useful for assessing MV function
• Cardiac MRI
Outcomes and prognosis
• Low early mortality
– 2-13%
• Acceptable 5 and 10 year mortality
– 5 year survival 58-80%
– 10 year survival 30% ( better than medical Tx)
• Most patients experience increased LV performance
– LVEF↑ Pulm pressure↓ LV volume↓ MV O2
demand ↓ Exercise tolerance ↑
• Scientific evidence to be collected through the STICH trial
The STICH trial (Surgical Treatment for Ischemic Heart Failure)
• Target registry 2800 patients with 90 participating
centers
• Objectives to seek best treatment for
coronary disease and heart failure
(Inclusive of SVR)
• Groups
– Medical therapy alone
– Medical therapy & CABG
– Medical therapy & CABG and SVR
AMC experience • Duration : 1991 – 2008. 3 월 n=60
• M 52 명 (85%) Mean age : 60.6
Preop NYHA functional class
I 1
II 12
III 35
IV 13
78% of the patients were in functional class III or IV
Associated conditions
3VD 50 (82%)
Preop IABP 4 (7%)
Preoperative echocardiogram
Parameter Value
EF(%) 31.0±10.0
LVIDs (mm) 48.5±10.1
LVIDd (mm) 61.1±8.5
LVESV (ml) 124.3±57.4
LVEDV (ml) 173.5±67.1
Surgical Method
Surgery Value Pication 3Linear repair 28Endoventricular patch 30
Concom. Proced .CABG 59
(96.7) Ring 6 Double orifice 4Pap m. imbrication 3Posterior annuloplasty 5
Serial Echo FindingsSerial Echo Findings
EF LV volume
Preop 38 % 133 ml
Immediate 25 % 111 mlpostop
Postop 2 36 % 103 ml
Post op 3 48 % 63 ml(3 years later)
P value
EF(%)
Preop. 53.5±12.1 55.0±12.6 NS
Immdiate Postop. 54.1±9.5 56.7±13.2 NS
CT finding
Non-visualization 0(0) 0(0) NS
Faint(%)
LAD 1(2.7) 3(15.0) NS
V1 0(0) 1(5.0) NS
V2 0(0) 0(0) NS
V3 1(7.7) 0(0) NS
LIMA TRA(n=23)SVGseq (n=37)
Prevention of IMR does not prevent LV remodelling after posterolateral MI
J Am Coll Cardiol;43(3):377-83
The key to treating chronic infarction induced heart failure is to treat the underlying cause of the remodeling process