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ORIGINAL ARTICLE

Early and late results of surgical correction of left ventricle aneurysms

Jarbas J DinkhuysenI; Magaly SantosII; Luiz Carlos Bento de SouzaI; Paulo ChaccurI; Camilo Abdulmassih Neto; Antoninho S ArnoniIII; Ibrahim PintoI; Paulo P PaulistaIII; Adib D JateneII

DOI: 10.1590/S0102-76381993000300007

ABSTRACT

We revewed 305 cases with left ventricular aneurysms undertaken to surgery from January 84 to December 91 analising early results since the late follow-up that ranged from 8 months to 8.5 years, and included all patients discharged alive from hospital. There were 88.5% male, with age ranging from 33 to 78 years (46% of patients between 51 to 60 years). The most frequent clinical finding was chest pain (73.3%), followed byheartfailure (45.9%), arrhythmias (24.9%). Fifty four percent of the patients were in functional class 1,5.2% in II, 12.7% in III and 28.7% in class IV. Left ventricular angiogram showed aneurysms and diskinesis in all cases, and coronary angiography showed single vessel coronary artery disease (CAD) in 20.9%, 2 vessel CAD in 45.9%, 3 vessel CAD in 25.9% and 4 or more vessels CAD in 7.2%. Patients were divided in groups according to left ventricular wall motion of the non aneurysmatic areas. There was 34.7% in the good group (mean wall motion = 0.58), 54.7% in the regular group (mean wall motion = 0.35) and 10.4% in the bad group (mean wall motion = 0.22). The used surgical technique included the observation of the beating heart under bypass auxiliary. This aided the differentation of fibrostic and contracting areas. This also allowed better preservation of the physiology of the myocardium during the procedure. In selected cases after opening the aneurysm and removing thrombus, coronaries were revascularized with intermitent aortic clampping (32oC) with cavity reconstrution at the end of the procedure. Isolated aneurismectomy was performed in 23.2%, associated myocardial revascularization in 77.3% other procedures in 1.3%. Overall in hospital mortality was 6.2%, 2% in the good group, 2.9% in the regular and 34.3% in the bad group. Two hundred and eight six patients (93.8%) men discharged, 44.3% asymptomatic (good 60%, regular 40%, bad 57.1%). There were 7.6% late deaths, 4.8% in the good group, 7.4% in the regular and 23.8% in the bad group. By the analysis of the actuarial curves (up to 8.5 years) the authors conclude that the life expectancy of patients with left ventricule aneurysms undertaken to surgery with or without associated procedures changes according to wall motion in the residual areas, being 85.5% in patients with mean motion of 0.58, 87.7% with mean wall motion 0.35 and 59.3 to patients with mean wall motion of 0.22%.

RESUMO

Foram analisados 305 casos operados entre janeiro de 1984 e dezembro de 1991, abrangendo os resultados imediatos e a evolução tardia, de 8 meses a 8,5 anos de pacientes operados de aneurisma do VE. A evolução clínica a longo prazo foi integral, isto é, todos os pacientes que receberam alta hospitalar foram acompanhados. A maioria (88,5%) era masculina, com idade entre 33 e 78 anos, sendo que 46% dos pacientes se situavam entre 51 e 60 anos. O sintoma mais freqüente foi dor precordial (73,3%), insuficiência cardíaca (45,9%) e arritmias (24,9%). Quanto à classe funcional (NYHA) 54% dos pacientes estavam na classe 1,52% na classe II, 12,7% na classe III e 28,7% na classe IV, respectivamente. O estudo hemodinâmico revelou aneurisma e deiscência em todos os casos e com lesão coronária obstrutiva em 1 vaso em 20,9% dos pacientes, 2 vasos em 45,9%, 3 vasos em 25,9% e, finalmente, 4 ou mais vasos em 7,2% dos casos. De acordo com a fração de ejeção das porções contrateis do VE foram divididos em Grupo Bom (Fe = 0,58) 34,7% pacientes, Grupo Regular (Fe = 0,35) 54,7% pacientes e Grupo Ruim (Fe = 0,22) 10,4% pacientes. A técnica cirúrgica empregada foi a de corrigir com auxílio da CEC, o aneurisma, com o coração batendo, de maneira a permitir avaliação funcional das áreas contrateis versus fibrose, reconstruir a anatomia contrátil da melhor forma possível e preservar o miocárdio em condições fisiológicas durante o procedimento. Em casos selecionados, logo após a abertura do aneurisma e remoção dos trombos intracavitários, eram revascularizadas as artérias coronárias interessadas através de pinçamentos intermitentes, da aorta (32ºC), deixando-se a reconstrução da cavidade para o final do procedimento. A aneurismectomia isolada foi o único procedimento em 21,3% dos casos, associados a RM em 77,3% e a outros procedimentos em 1,3%. A mortalidade hospitalar global foi de 6,2% sendo de 2,8% no Grupo Bom, 2,9% no Grupo Regular e de 34,3% no Grupo Ruim. Obtiveram alta hospitalar 286 (93,8%) pacientes, dos quais 44,3% se encontram assintomáticos (Grupo Bom 60%, Grupo Regular 40%, Grupo Ruim 57,1%). Ocorreram 7,6% óbitos tardios, distribuídos no Grupo Bom 4,8%, Grupo Regular 7,4% e Grupo Ruim 23,8%. Analisando as curvas atuariais numa evolução até 8,5 anos, os autores concluem que a expectativa de vida para os portadores de aneurisma, de VE que se submetem a tratamento cirúrgico, com ou sem procedimentos associados, é de 85,5% com Fe = 0,58; 87,7% com Fe = 0,35 e 59,3% com Fe = 0,22.
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