**8. Discussion**

**Figure 4.** Patient K, has had an acute MI in the circulation of a left circumferential artery with a long area of subendo‐ cardial lesion of a lateral wall. Fig.4а – Т1- weighed spin-echo ECG-gated MRI study before injection of paramagnetic contrast; Fig. 4b – T1-weighted spin-echo ECG-gated MRI 15 min after injection of paramagnetics, as 2ml of 0,5M sol‐ ution per 10 kg of BW. Fig. 4c – the same as 4b, after semi-automatic bordering of subendocardial contrast uptake.

Patient T, 56 year old was admitted to the department of cardiovascular surgery at Tomsk Institute of Cardiology in 4 months after transmural anterior-septal myocardial infarction with complaints on occasional angina pangs and dyspnea. The patient was examined rou‐ tinely. Holter monitoring showed ventricular extrasystoly (grade III by Lown). By EchoCG ejection fraction was 25% lower than normal (in B mode), LV was dilated with LV EDVI as high as 154 ml/m2 and LV ESVI of 116 ml/m2; local LV contractility was disturbed, there was found akinesis of apical, medial septal and anterior segments as well as hypokinesis of

By MRI there were found postinfarction cicatricial changes in all apical and, ventricular sep‐ tal and anterior segments; perimeter of the affected LV endocardium was 43%. In the apical and septal segments TI varied from 0,35 to 0,56. Data of coronaroventriculography showed LV deformation due to the aneurysm on the plane of anterior-lateral and apical segments and due to atherosclerosis of coronary arteries which included occlusion of the LAD artery in its proximal third and 75% stenosis of the right coronary artery. After mapping and elec‐ troanatomical LV reconstruction (Figure 3) there were identified the areas of an "electrical scar" on the apex, ventricular septum and anterior LV wall, zones of delayed conduction (pink dots in the picture) and those of double potential (blue dots) in transient zone, around the scar on ventricular septum and partially on the lateral LV wall. On the border of affected areas and viable myocardium radiofrequent (RF) dotty tags were applied (maroon dots in

After careful examination the decision was made to perform surgical myocardial revascula‐ rization and LV endoventriculoplasty with endocardectomy of the affected area. During the

lateral and posterior-lateral segments. EchoCG also showed the 2nd type aneurysm.

**7. Clinical case**

328 Principles and Practice of Cardiothoracic Surgery

the picture) by an ablation lead.

In 1956 Couch O.A. performed LV aneurysm resection in a patient with VT thus beginning an era of surgical treatment of ventricular rhythm disorders [13].

It has been more than 50 years since; nevertheless the issue of complications and approaches of surgical treatment associated with the appearance of VT in patients with remodelled LV after previous MI is still quite challenging [14]. It was at that time already when specialists were aware of the fact that LV myocardium affected by infarction was a source of fatal ven‐ tricular rhythm disorders. Initially there were offered methods of indirect surgical interven‐ tion such as thoracic sympathectomy, CABG, resection of a cardiac wall for the treatment of recurrent ventricular arrhythmias associated with CAD [15,16,17]. Since these methods ap‐ peared to be inefficient, over the course of time there were implemented direct endocardial methods performed under control of intraoperative electrophysiological mapping. The first endocardial procedure developed for the treatment of VT combined with CAD was a circu‐ lar endocardial resection performed by Guiraudon in 1978 [18]. This procedure involves en‐ docardial incision made on the borderline between endocardial fibrosis and viable myocardium and continued around the whole base of aneurysm or infraction area. In 1982 to enhance efficiency of a circular endocardial resection J. Moran modified this procedure by resecting all the fibrous endocardium connected with LV aneurysm or infarction and called it an expanded endocardial resection [19]. Supporting development of the ideas referred to endocardial resection V.Dor offered resection of fibrous endocardium from the side of inter‐ ventricular septum during surgical LV reconstruction [11].

This kind of intervention appeared to be efficient for the treatment of «refractory» ischemic VTs but did not make any effect on VTs coming from papillary muscles' base or from areas adjacent to a ring of an aortic or mitral valves.

In 1981 Leo Bokeria one of the first in the world began resection of LV aneurysm and cardio‐ destruction in the areas of early activity after intraoperative epicardial EPhS [20]. Develop‐ ing cryosurgical methods of intervention in 1985 J.Cox performed endocardial cardiodestruction but the procedure resulted in lethal outcome in 27% of the cases and was ineffective in 17% of the cases [15]. I 1980th M.Mirovsky (the USA) offered an alternative method of VT treatment – implantation of cardioverter-defibrillator [21].

**Figure 6.** Actuarial survival curve depending on a type of VT (Kaplan-Meier); p=0,00739 (Bokeria L.A et al.// Journal of

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia

http://dx.doi.org/10.5772/54126

331

**Figure 7.** Actuarial survival curve depending on VT relapse (Kaplan-Meier); p=0,012 (Bokeria L.A et al.// Journal of

Thoracic and Cardiovascular Surgery –1999.– №6.).

Thoracic and Cardiovascular Surgery –1999.– №6.).

As a result, for the treatment of postinfarction LV aneurysms and associated ventricular ta‐ chyarrhythmias there have been used different methods, either alone or in combination. Sig‐ nificant clinical experience have been acquired.

Thus, Bokeria L.A. in his study including 59 patients demonstrated a clear dependence of actuarial survival rate from the type of tachycardia and from the presence of VT relapse in the early postoperative period [20]; the worst prognosis was noticed with the presence of polymorphic ventricular extrasystoly (Figures 6, 7).

Interesting data were presented by the group of authors headed by M. Di Donato [22]; they analyzed data of 382 patients proving that spontaneous VTs after surgical treatment of LV aneurysms and VT significantly worsen prognosis for late postoperative period if compare with induced VTs of cases without arrhythmias (Figure 8).

After careful study of immediate ablation results in 71 patients with LV aneurysm and VT J. Pirk showed that epicardial cryoablation alone was successful in 63,3% of the cases and aneurysmectomy and endocardial cryoablation and/or subendocardial resection were suc‐ cessful in 73,2% of the cases [23].

Sartipy U. studying combination of V. Dor procedure and surgery for VT in 53 patients came to the conclusion that combination of these procedures keeps survival rate high in the postoperative period (Figure 9) and that majority of the patients did not need implantation of an automatic implantable cardioverter-defibrillator (AICD) [24].

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia http://dx.doi.org/10.5772/54126 331

tion such as thoracic sympathectomy, CABG, resection of a cardiac wall for the treatment of recurrent ventricular arrhythmias associated with CAD [15,16,17]. Since these methods ap‐ peared to be inefficient, over the course of time there were implemented direct endocardial methods performed under control of intraoperative electrophysiological mapping. The first endocardial procedure developed for the treatment of VT combined with CAD was a circu‐ lar endocardial resection performed by Guiraudon in 1978 [18]. This procedure involves en‐ docardial incision made on the borderline between endocardial fibrosis and viable myocardium and continued around the whole base of aneurysm or infraction area. In 1982 to enhance efficiency of a circular endocardial resection J. Moran modified this procedure by resecting all the fibrous endocardium connected with LV aneurysm or infarction and called it an expanded endocardial resection [19]. Supporting development of the ideas referred to endocardial resection V.Dor offered resection of fibrous endocardium from the side of inter‐

This kind of intervention appeared to be efficient for the treatment of «refractory» ischemic VTs but did not make any effect on VTs coming from papillary muscles' base or from areas

In 1981 Leo Bokeria one of the first in the world began resection of LV aneurysm and cardio‐ destruction in the areas of early activity after intraoperative epicardial EPhS [20]. Develop‐ ing cryosurgical methods of intervention in 1985 J.Cox performed endocardial cardiodestruction but the procedure resulted in lethal outcome in 27% of the cases and was ineffective in 17% of the cases [15]. I 1980th M.Mirovsky (the USA) offered an alternative

As a result, for the treatment of postinfarction LV aneurysms and associated ventricular ta‐ chyarrhythmias there have been used different methods, either alone or in combination. Sig‐

Thus, Bokeria L.A. in his study including 59 patients demonstrated a clear dependence of actuarial survival rate from the type of tachycardia and from the presence of VT relapse in the early postoperative period [20]; the worst prognosis was noticed with the presence of

Interesting data were presented by the group of authors headed by M. Di Donato [22]; they analyzed data of 382 patients proving that spontaneous VTs after surgical treatment of LV aneurysms and VT significantly worsen prognosis for late postoperative period if compare

After careful study of immediate ablation results in 71 patients with LV aneurysm and VT J. Pirk showed that epicardial cryoablation alone was successful in 63,3% of the cases and aneurysmectomy and endocardial cryoablation and/or subendocardial resection were suc‐

Sartipy U. studying combination of V. Dor procedure and surgery for VT in 53 patients came to the conclusion that combination of these procedures keeps survival rate high in the postoperative period (Figure 9) and that majority of the patients did not need implantation

ventricular septum during surgical LV reconstruction [11].

method of VT treatment – implantation of cardioverter-defibrillator [21].

adjacent to a ring of an aortic or mitral valves.

330 Principles and Practice of Cardiothoracic Surgery

nificant clinical experience have been acquired.

polymorphic ventricular extrasystoly (Figures 6, 7).

cessful in 73,2% of the cases [23].

with induced VTs of cases without arrhythmias (Figure 8).

of an automatic implantable cardioverter-defibrillator (AICD) [24].

**Figure 6.** Actuarial survival curve depending on a type of VT (Kaplan-Meier); p=0,00739 (Bokeria L.A et al.// Journal of Thoracic and Cardiovascular Surgery –1999.– №6.).

**Figure 7.** Actuarial survival curve depending on VT relapse (Kaplan-Meier); p=0,012 (Bokeria L.A et al.// Journal of Thoracic and Cardiovascular Surgery –1999.– №6.).

Contemporary therapeutic methods are not able to solve this problem also. By the data of a multicenter trial MADIT II implantation of AICD in patients with ventricular rhythm distur‐ bances lowers the risk of a sudden cardiac death for 31 % which is more efficient than anti‐ arrhythmic therapy but still is not 100% saving [21]. In a year after endovascular treatment of VT the rate of relapses comprises 20% [25,26]. Nevertheless, antiarrhythmic therapy, im‐ plantation of AICD, catheter isolation of ectopic focuses do not touch an issue of coronary

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia

http://dx.doi.org/10.5772/54126

333

According to the data of a multicenter STICH trial there were no significant differences found between the patients with ICMP and postinfarction LV aneurysm subjected to CABG only (group 1) and those subjected to CABG with LV reconstruction (group 2) during 5 year follow-up. Nevertheless, postoperatively AICD was implanted into 20% of the patients from group 1 and into 17% from group 2 [27]. The study did not suppose to perform extended endocardectomy during LV reconstruction. Taking into account the aforesaid, one may claim that almost every 5th patient is destined for AICD implantation after surgical remodeling of LV. Although, by the data of multiple authors endocardial resection either with intraoperative mapping or without it prevents VT paroxysms in

Thus, we saw clearly that at that time to treat patients with postinfarction LV aneurysm complicated with ventricular rhythm disorders is was necessary to perform reconstruction of LV cavity with endocardial resection and CABG; to use contemporary antiarrhythmics

Though, at that point there were unclear issues connected with topical diagnostics of poten‐ tial re-entry zones which was important for adequate resection of affected endocardium. In our study we tried to enhance efficacy of topical diagnostics and surgical treatment of the patients with postinfarction LV aneurysm complicated with VT, due to combined applica‐ tion of contrast-enhanced MRI, EPhS and advanced surgical treatment (SVR and EE). It is well-known that MRI is a golden standard in diagnostics of LV aneurysm [4, 28], but MRI data may provide only indirect evidences about the presence of arrhythmogenic zones.

Prognostic role of contrast-enhanced MRI in evaluation of myocardial viability were report‐ ed in literature in as far as 1986 [29]. In particular, it was supposed, that with the presence of irreversible ischemic lesion of myocardium MRI made at rest demonstrated significant de‐ crease of end-diastolic thickness of myocardium (EDTM) and simultaneously – contractility index. At the same time it was assumed that secure thickness of myocardium evaluated by

Comparison of myocardial MRI made at rest with the results of PET with 18F-FDG and SPECT with repeated injection of tallim-201 in patients with chronic coronary disease and pronounced LV dysfunction was made in a number of studies [30]. It was found, that as a rule MRI visualized secure thickness of myocardium and the value of EDTM more than 5,5-6,0 mm in the affected areas in LV segments classified as viable by PET and SPECT. Lat‐ er, Baer et al [31] making a direct comparison of MRI at rest and PET data with 18F-FDG found that with EDTM ≤ 5,5mm there were no signs of viability on myocardial tomography

the value EDTM meant also a secure viability of myocardium in that location.

arteries lesion.

90% of the cases and more [19, 24].

and AICD implantation in postoperative period if necessary.

**Figure 8.** Kaplan-Meier survival curves by the groups with VT in postoperative period (months) after surgical treat‐ ment of LV aneurysm and VT. (Di Donato et al. Seminars in Thorac and Cardiovasc Surg.Vol.13;4:480-485).

**Figure 9.** Overall actuarial survival after the Dor procedure including ventricular tachycardia surgery. Dotted curves are upper and lower 95% confidence intervals (Sartipy U. et al.; Ann Thorac Surg 2006;81:65-71).

Contemporary therapeutic methods are not able to solve this problem also. By the data of a multicenter trial MADIT II implantation of AICD in patients with ventricular rhythm distur‐ bances lowers the risk of a sudden cardiac death for 31 % which is more efficient than anti‐ arrhythmic therapy but still is not 100% saving [21]. In a year after endovascular treatment of VT the rate of relapses comprises 20% [25,26]. Nevertheless, antiarrhythmic therapy, im‐ plantation of AICD, catheter isolation of ectopic focuses do not touch an issue of coronary arteries lesion.

According to the data of a multicenter STICH trial there were no significant differences found between the patients with ICMP and postinfarction LV aneurysm subjected to CABG only (group 1) and those subjected to CABG with LV reconstruction (group 2) during 5 year follow-up. Nevertheless, postoperatively AICD was implanted into 20% of the patients from group 1 and into 17% from group 2 [27]. The study did not suppose to perform extended endocardectomy during LV reconstruction. Taking into account the aforesaid, one may claim that almost every 5th patient is destined for AICD implantation after surgical remodeling of LV. Although, by the data of multiple authors endocardial resection either with intraoperative mapping or without it prevents VT paroxysms in 90% of the cases and more [19, 24].

Thus, we saw clearly that at that time to treat patients with postinfarction LV aneurysm complicated with ventricular rhythm disorders is was necessary to perform reconstruction of LV cavity with endocardial resection and CABG; to use contemporary antiarrhythmics and AICD implantation in postoperative period if necessary.

**Figure 8.** Kaplan-Meier survival curves by the groups with VT in postoperative period (months) after surgical treat‐

**Figure 9.** Overall actuarial survival after the Dor procedure including ventricular tachycardia surgery. Dotted curves are

upper and lower 95% confidence intervals (Sartipy U. et al.; Ann Thorac Surg 2006;81:65-71).

ment of LV aneurysm and VT. (Di Donato et al. Seminars in Thorac and Cardiovasc Surg.Vol.13;4:480-485).

332 Principles and Practice of Cardiothoracic Surgery

Though, at that point there were unclear issues connected with topical diagnostics of poten‐ tial re-entry zones which was important for adequate resection of affected endocardium. In our study we tried to enhance efficacy of topical diagnostics and surgical treatment of the patients with postinfarction LV aneurysm complicated with VT, due to combined applica‐ tion of contrast-enhanced MRI, EPhS and advanced surgical treatment (SVR and EE). It is well-known that MRI is a golden standard in diagnostics of LV aneurysm [4, 28], but MRI data may provide only indirect evidences about the presence of arrhythmogenic zones.

Prognostic role of contrast-enhanced MRI in evaluation of myocardial viability were report‐ ed in literature in as far as 1986 [29]. In particular, it was supposed, that with the presence of irreversible ischemic lesion of myocardium MRI made at rest demonstrated significant de‐ crease of end-diastolic thickness of myocardium (EDTM) and simultaneously – contractility index. At the same time it was assumed that secure thickness of myocardium evaluated by the value EDTM meant also a secure viability of myocardium in that location.

Comparison of myocardial MRI made at rest with the results of PET with 18F-FDG and SPECT with repeated injection of tallim-201 in patients with chronic coronary disease and pronounced LV dysfunction was made in a number of studies [30]. It was found, that as a rule MRI visualized secure thickness of myocardium and the value of EDTM more than 5,5-6,0 mm in the affected areas in LV segments classified as viable by PET and SPECT. Lat‐ er, Baer et al [31] making a direct comparison of MRI at rest and PET data with 18F-FDG found that with EDTM ≤ 5,5mm there were no signs of viability on myocardial tomography slices during radionuclide study. As for prognosis for restoration of myocardial viability and contractility after CABG in such patients, their criterion { EDTM ≤ 5,5 mm } had high sensitivity up to 92-95%, but low specificity – just about 56-60%.

there and made for a high risk for the patients' lives. Contrast-enhanced MRI gives addition‐ al prognostic information about arrhythmogenisity of particular areas and segments of LV after myocardial infarction. More often arrhythmogenic areas are located in the areas of a

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia

Thus, data of contrast-enhanced MRI not only have diagnostic significance concerning a de‐ gree of a cardiac muscle lesion but also identify arrhythmogenisisty of this or that myocar‐ dial area. In surgical treatment of postinfarction aneurysm endocardectomy of scarred and transient LV zones' endocardium is an inseparable stage to prevent VT spells. MRI and en‐ docardial EPhS with electroanatomical LV reconstruction allow to find potential areas

, Sergey Andreev1

2 Department of Diagnostic Radiology and Tomography, Tomsk Institute of Cardiology,

[1] Di Donato, M Ventricular arrhythmias after LV remodeling: surgical ventricular re‐

[2] Arai A.E. The cardiac magnetic resonance (CMR) approach to assessing myocardial

[3] Carlsson M., Arheden H., Higgins C.B., Saeed M Magnetic resonance imaging as po‐ tential gold standard for infarct quantification. J Electrocardiol 2008; 41 614-620. [4] Dor, V., Sabatier M., Montiglio F Endoventricular patch reconstruction of Ischemic failing ventricle: A single center with 20 years experience Heart Fail Rev 2004; 9

3 Department of Heart Rhythm Disorders, Tomsk Institute of Cardiology, Tomsk, Russia

1 Cardiovascular Surgery Department, Tomsk Institute of Cardiology, Tomsk, Russia

and Sergey Popov3

, Vladimir Usov2

, Ruslan Aimanov1

http://dx.doi.org/10.5772/54126

335

,

pronounced non-transmural lesion of LV myocardium with TI higher than 0,27.

**9. Conclusion**

where re-entry may occur.

Vladimir Shipulin1\*, Vadim Babokin1

, Roman Batalov3

storation or ICD. Heart Fail. Rev. 2005;9(4) 299-306.

viability. J.Nucl. Cardiol 2011; 18 1095-1102.

\*Address all correspondence to: shipulin@cardio.tsu.ry

**Author details**

Anthony Bogunetsky1

Tomsk, Russia

**References**

269-286.

As a rule, for contrast-enhanced MRI visualization of affected myocardium contrasting agents – paramegnetics are used, usually they are complexes of Gd or Mn with derivatives or analogues of diaethylentriaminpentacetic acid (DTPA). Their intravenous bolus injection makes possible qualitative evaluation of myocardial perfusion by the degree of changing brightness of myocardial image during the first few seconds after injection. Later on, in 12-20 minutes after injection one can evaluate the picture of myocardial lesion by accumula‐ tion of contrasting agent in affected areas.

There exist an established and commonly accepted opinion that transmural accumulation of paramagnetics in myocardium during contrast-enhanced MRI means irreversible lesion, and lack of accumulation vice versa evidences viability of myocardium and makes for favoura‐ ble prognosis [32]. Nevertheless, relationship of contrast-enhanced MRI picture with the possibility of arrhythmogenesis in this or that myocardial area is still of a great interest.

Electrophysiological mechanism of the observed interrelationship between results of cardiac contrast-enhanced MRI and decrease of electrical potential in a definite LV segment is noth‐ ing but a particular case of a well-studied pathogenesis of arrhythmias appearance in the area of ischemic myocardial lesion [33].

It is in the area of thickened and partially replaced by subendocardial scarred tissue of myo‐ cardium where one can notice lowered electrical potential proportionally to the lowering mass of viable myocardium. This fact, in its turn, is favorable for the functioning of local reentry circuits which are electrophysiological basis for ventricular tachycardias [33, 34].

That is why during contrast-enhanced MRI it makes sense to calculate TI index value in all the cases keeping in mind further electrophysiological study and evaluation of risks for ven‐ tricular tachycardias. Epicardial mapping provides information about the presence of excite‐ ment zones in LV and approximate anatomy of their localization for a further surgical treatment [4, 35]. Preoperative endocardial EPhS with electroanatomical LV reconstruction is able to demonstrate vividly disturbances in cardiac conduction system. Examining the re‐ sults of endocardial EPhS we found consistency of myocardial lesion and its elctrophysio‐ logical properties. In patients suffered from extensive myocardial infarction complicated with aneurysm one can identify zones of low-amplitude ventricular potential less than 0,5mV which is a scarred zone more often anatomically involving an apex of LV with a part of anterior wall and ventricular septum. Viable myocardium has potential amplitude higher than 1,5 mV. A subject of a special interest is a transient zone from 0,5 to 1,5 mV situated between the scar and viable myocardium where they register double potential and/or de‐ layed conduction able to cause re-entry and ventricular tachycardia; a surgeon is just to per‐ form dissection of affected endocardium. EPhS and MRI allow to identify borders for endocardial dissection.

Postoperative EPhS worth electroanatomical LV reconstruction performed in patients with‐ out endocardectomy showed that re-entry and VT sources revealed preoperatively were still there and made for a high risk for the patients' lives. Contrast-enhanced MRI gives addition‐ al prognostic information about arrhythmogenisity of particular areas and segments of LV after myocardial infarction. More often arrhythmogenic areas are located in the areas of a pronounced non-transmural lesion of LV myocardium with TI higher than 0,27.
