Exploration Of Surgical Treatment Strategies For Ventricular Aneurysm

China has faced a rapidly growing population with coronary artery disease(CAD).The number of this entity is estimated to exceed 11 million,incurring social and economic burden.Myocardial infarction(MI)and subsequent left ventricular aneurysm(LVA)which CAD has caused will lead to left ventricular remodeling and heart failure if not interfered properly.Surgical treatment of left ventricular aneurysm appeared sixty years ago.Observational studies revealed that left ventricular reconstruction(LVR)reduced volume and restored shape,improving clinical outcomes.However,the Surgical Treatment for Ischemic Heart Failure(STICH)trial,regarded as the only randomized controlled trial up-to-date and published in the New England Journal of Medicine in 2009,contradicted the clinical benefit of left ventricular reconstruction.This study was based on the database of Fuwai Hospital which comprised of 1398 patients undergoing left ventricular reconstruction from 1999 to 2017.We aim to illustrate the clinical characteristics and identify the responders to this surgical procedure.In addition,surgical treatment of left ventricular aneurysm was further explored in subgroup of patients which had ischemic mitral regurgitation and non-obstructive coronary artery disease,respectively.Part ?Background:The purpose of this study was to develop and validate a risk model for elucidating predictive factors of mortality in patients with left ventricular aneurysm undergoing left ventricular reconstruction(LVR).Methods:The study included 1233 patients who underwent LVR and coronary artery bypass graft(CABG)in our center between 1999 and 2017.A Cox proportional hazards model was used to assess the potential predictors of mortality with a bootstrap simulation procedure,and a risk scoring system was developed and validated.Results:Operative mortality was 1.1%(14/1233).Four independent predictors of long-term mortality were identified:body mass index(BMI),prior stroke,diabetes mellitus(DM)and preoperative mitral regurgitation(MR).Overall,Harrell's C statistic was 0.742(95%CI,0.650-0.834),and the integrated time-dependent area under the curve(AUC)was 0.751.Model calibration was good according to the Hosmer-Lemeshow test(P>0.05).The risk score model stratified 24.8%,41.0%,and 34.2%of patients into high-(?8 points),intermediate-(6-7 points),and low-risk(0-5 points)groups,with probabilities of 0.11,0.06,and 0.03 for 8-year mortality,respectively.Conclusions:We developed and validated a risk model for elucidating predictive factors of mortality in patients with left ventricular aneurysm undergoing LVR.This risk model assigned a risk profile to a subgroup of patients with left ventricular aneurysm and could potentially aid in the decision-making process for the timing and choice of intervention for LVR.Part ?Background:This study aims to compare the mid-term outcomes of left ventricular reconstruction(LVR group)with that of left ventricular reconstruction plus mitral valve surgery(LVR-MV group)in patients with left ventricular aneurysm due to anterior myocardial infarction and moderate mitral regurgitation.Methods:523 patients(75 with LVR-MV surgery and 448 with LVR)with concomitant moderate mitral regurgitation were included in the study population.All-cause mortality was considered as primary endpoints.Major adverse cardiovascular and cerebrovascular events(MACCE),including a composite of death,myocardial infarction,stroke and subsequent mitral-valve surgery,was considered as secondary endpoints.Multivariable proportional hazards cox regression models were used to assess association between groups and outcomes.In sensitivity analysis,we excluded patients who did not undergo coronary artery bypass graft(CABG)and repeated statistical analysis above.Results:Median follow-up time was 41 months among all patients.There was no significant difference between LVR-MV group and LVR group with regard to all-cause mortality(p=0.208)and MACCE(p=0.817)after adjustment with covariates,respectively.In sensitivity analysis,there was no significant difference between LVR-MV group and LVR group with regard to all-cause mortality(p=0.158)and MACCE(p=0.651)after adjustment with covariates,respectively.Conclusions:LVR demonstrates comparable clinical outcomes with LVR-MV surgery in patients with left aneurysm and moderate mitral regurgitation.This suggested that LVR may be an optional surgical procedure to address moderate mitral regurgitation for this high-risk subgroup,obviating the need to intervene with mitral valve.Part ?Background:There is a paucity of studies examining the treatment of patients with prior myocardial infarction in the absence of obstructive coronary arteries(MINOCA)and with concomitant left ventricular aneurysm.Our study aims to illustrate the clinical characteristics and report the mid-term surgical outcomes in this distinct entity.Methods and Results:Ten patients with MINOCA and left ventricular aneurysm were investigated.The MINOCA was diagnosed according to Scientific Statement from the American Heart Association.The indication for left ventricular reconstruction were as follows:clear evidence of both an aneurysmal and akinetic left ventricle with a history of myocardial infarction accompanied by heart failure symptoms,angina or ventricular arrhythmias.Major adverse cardiovascular and cerebrovascular event(MACCE),including death,myocardial infarction,stroke was considered primary endpoint.The median follow-up for the whole study population was 64.5 months.Seven MINOCA patients developed left ventricular aneurysm within 4 years and three MINOCA patients were found to have concomitant left aneurysm at the first admission.Before surgery,no patients prescribed with angiotensin converting enzyme inhibitors.Statins,dual antiplatelet therapy,and ?-blockers were prescribed in 2,5 and 5 patients,respectively.After surgery,no MACCE occurred in the follow-up.There was significant increase in ejection fraction(EF)in the follow-up(p=0.0009).Conclusions:Close monitoring and standard medical treatment is required before left ventricular aneurysm occur in MINOCA patients.Left ventricular reconstruction remains a viable option for MINOCA patients with left aneurysm and mid-term outcomes were satisfying in this distinct entity.