**2. Materials and methods**

The study included 188 patients operated for postinfarction anterior septal and apical LVA. The disease was diagnosed basing on the data of echocardiography (EchoCG), coronary ventriculography (CVG) and contrast-enhanced MRI.

Prior to the surgery the patients mostly had III-IV CC angina class, their condition corre‐ sponded to that of New York Heart Association (NYHA) class II-III for chronic heart failure. All the patients demonstrated evidence of postinfarction LV remodeling according to the re‐ sults of ventriculography and EchoCG.

Cardiac inversion recovery and T-1 spin-echo weighed MRI study with ECG synchronization was performed with a patient lying flat with no additional functional stress. Axial slices on the level of thorax with the complete coverage of heart area were recorded. The field of view was 350-380 mm wide and 7-8mm thick slices were recorded into the matrix of 256x256 voxels. Syn‐ chronization of the recordings of MRI pictures with ECG was performed by standard means of an open PRI scanner Magnetom-Open (0,2 T by Siemens Medical) or high field open MRI scan‐ ner Vantage Titan (1,5 Т, by Toshiba) by R-wave of ECG; end-diastolic images were acquired in all the cases. Parameters of the acquired T1-weighed images in spin-echo mode were as fol‐ lows: repetition time (TR) 550 – 1040ms, echo time (TE) – 20 ms. MRI included slices with long axis two-chamber and four-chamber views as well as short axis view covering all the myocar‐ dial volume of LV. The study was performed in 12-20 minutes after injection of paramagnetic contrast agents with the concentration of paramagnetic agent itself of 0,5М (Omniscan, Mag‐ nevist, Optimark, Cyclomang, Viewgam) in dosage of 2ml/10kg of a body weight. The shortaxis and long-axis slices in four-chamber view were divided semi-automatically into 17 segments taking into account generally accepted segmentation of LV myocardium (Fig.1) [7].

**Figure 1.** Segmentation of LV myocardium, used in evaluation of a local paramagnetic contrast agent uptake during

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia

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

323

**Figure 2.** The scheme of TI calculation by the data of delayed contrast-enhanced MRI of myocardium. The values of thickness of the infarction zone (accumulation of paramagnetic) and the value of the total myocardial thickness were identified on the LV slices in short axis. Thickness of the contrast-paramagnetic accumulation in myocardium is thought to be the thickness of lesion resulting from acute myocardial infarction. Thus TI is equal to *{(thickness of an*

*infracted area)/ (thickness of the myocardium)}.* (original data)

myocardial MRI

In particular, for each segment i (i = 1 – 17) we calculated the depth of damage by the degree of paramagnetic contrast agent uptake as follows: [Index of Transmurality]i = (maximum thicknesses of paramagnetic contrast agent uptake)i / (thickness of myocardium in a particu‐ lar segment) i (Figure 2). (original data)

To see the association between MR images with the data of electrophysiological condition of heart muscle, and in particular with the location of the areas with lowered voltage of local electrical activity, the patients underwent electrophysiological study of the heart (EPhS) with electroanatomical CARTO reconstruction of LV [20]. Besides, there were identified the areas of delayed conduction, zones of possible re-entry and inducible VT (Figure 3).

Locations of intracardiac leads and thus of segmental electrical activity corresponded to the lo‐ cations of left ventricular segments during contrast-enhanced MRI. In accordance with the am‐ plitude of the curve during EPhS for a definite myocardial segment, degree of potential reduction was graded as follows: 0 – for the amplitude of the potential from 1,5 to 8 mV, when the segment was considered to be a zone of normal potential; 1 — for the amplitude of 0,5 — 1,5 mV, a transient zone; 2 — for the amplitude 0,05 — 0,5 mV, low potential zone; 3 — zone of «electrical scar» - lack of electrical activity when the amplitude was 0 — 0,05 mV. This grading was precon‐ ditioned by the fact that myocardial areas with the 1st or 2nd grades of lowered potential were, as a rule, sources of life threatening tachycardias, while for grade 3 "electrical scar" this was less pos‐ sible and in the zones with normal electrical activity of grade 0 VTs did not occur [9,10].

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia http://dx.doi.org/10.5772/54126 323

**2. Materials and methods**

322 Principles and Practice of Cardiothoracic Surgery

sults of ventriculography and EchoCG.

lar segment) i (Figure 2). (original data)

ventriculography (CVG) and contrast-enhanced MRI.

The study included 188 patients operated for postinfarction anterior septal and apical LVA. The disease was diagnosed basing on the data of echocardiography (EchoCG), coronary

Prior to the surgery the patients mostly had III-IV CC angina class, their condition corre‐ sponded to that of New York Heart Association (NYHA) class II-III for chronic heart failure. All the patients demonstrated evidence of postinfarction LV remodeling according to the re‐

Cardiac inversion recovery and T-1 spin-echo weighed MRI study with ECG synchronization was performed with a patient lying flat with no additional functional stress. Axial slices on the level of thorax with the complete coverage of heart area were recorded. The field of view was 350-380 mm wide and 7-8mm thick slices were recorded into the matrix of 256x256 voxels. Syn‐ chronization of the recordings of MRI pictures with ECG was performed by standard means of an open PRI scanner Magnetom-Open (0,2 T by Siemens Medical) or high field open MRI scan‐ ner Vantage Titan (1,5 Т, by Toshiba) by R-wave of ECG; end-diastolic images were acquired in all the cases. Parameters of the acquired T1-weighed images in spin-echo mode were as fol‐ lows: repetition time (TR) 550 – 1040ms, echo time (TE) – 20 ms. MRI included slices with long axis two-chamber and four-chamber views as well as short axis view covering all the myocar‐ dial volume of LV. The study was performed in 12-20 minutes after injection of paramagnetic contrast agents with the concentration of paramagnetic agent itself of 0,5М (Omniscan, Mag‐ nevist, Optimark, Cyclomang, Viewgam) in dosage of 2ml/10kg of a body weight. The shortaxis and long-axis slices in four-chamber view were divided semi-automatically into 17 segments taking into account generally accepted segmentation of LV myocardium (Fig.1) [7]. In particular, for each segment i (i = 1 – 17) we calculated the depth of damage by the degree

of paramagnetic contrast agent uptake as follows: [Index of Transmurality]i

thicknesses of paramagnetic contrast agent uptake)i / (thickness of myocardium in a particu‐

To see the association between MR images with the data of electrophysiological condition of heart muscle, and in particular with the location of the areas with lowered voltage of local electrical activity, the patients underwent electrophysiological study of the heart (EPhS) with electroanatomical CARTO reconstruction of LV [20]. Besides, there were identified the

Locations of intracardiac leads and thus of segmental electrical activity corresponded to the lo‐ cations of left ventricular segments during contrast-enhanced MRI. In accordance with the am‐ plitude of the curve during EPhS for a definite myocardial segment, degree of potential reduction was graded as follows: 0 – for the amplitude of the potential from 1,5 to 8 mV, when the segment was considered to be a zone of normal potential; 1 — for the amplitude of 0,5 — 1,5 mV, a transient zone; 2 — for the amplitude 0,05 — 0,5 mV, low potential zone; 3 — zone of «electrical scar» - lack of electrical activity when the amplitude was 0 — 0,05 mV. This grading was precon‐ ditioned by the fact that myocardial areas with the 1st or 2nd grades of lowered potential were, as a rule, sources of life threatening tachycardias, while for grade 3 "electrical scar" this was less pos‐

areas of delayed conduction, zones of possible re-entry and inducible VT (Figure 3).

sible and in the zones with normal electrical activity of grade 0 VTs did not occur [9,10].

= (maximum

**Figure 1.** Segmentation of LV myocardium, used in evaluation of a local paramagnetic contrast agent uptake during myocardial MRI

**Figure 2.** The scheme of TI calculation by the data of delayed contrast-enhanced MRI of myocardium. The values of thickness of the infarction zone (accumulation of paramagnetic) and the value of the total myocardial thickness were identified on the LV slices in short axis. Thickness of the contrast-paramagnetic accumulation in myocardium is thought to be the thickness of lesion resulting from acute myocardial infarction. Thus TI is equal to *{(thickness of an infracted area)/ (thickness of the myocardium)}.* (original data)

**Characteristics**

Angina class Canadian Cardiovascular Society,

Current NYHA heart failure class, (%)

Ventricular tachycardia,

Mitral regurgitation 2+, fibrous ring more than 35

**Table 1.** Clinical characteristics of the patients.

(%)

mm, (%)

Lesions of coronary arteries, (%)

(%)

**LVR with EE n=84**

Diagnostics and Surgical Treatment of Left Ventricular Aneurysm with Ventricular Tachycardia

II 10 10 III 37 40 IV 34 33

Unstable angina 19 17

I 5 6 II 20 21 III 70 69 IV 5 4%

2 35 34 3 9 8

Spontaneous 14 13

Induced 32 30

1 30 34 2 35 36 3 35 30

18 13

Age, years old 55 56

Type of LV aneurysm, (%) 1 56 58

Ventricular extrasystoly, (%) 44 48

SSPS 11.5 for Windows software was used for the analysis. Shapiro-Wilk test was applied to assess normality of distribution law of quantitative values. The parameters conforming with the normal distribution test were described with the use of a mean value (M) and a standard deviation (SD). Qualitative data were described by the rate of occurrence or its percentage. Student's t-test was used to evaluate significance of the differences of quantitative values in the compared groups when distribution law was normal. To see the significance of differen‐ ces among quantitative values Z criterion (Fisher's exact test) was used. Evaluation of signif‐ icance of differences in postoperative mortality was carried out by Kaplan-Meier method.

With p<0.05 all the statistical parameters were considered significant.

**LVR without EE n=104**

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

325

**Figure 3.** Patient T, 56 year old. Before the surgery. EPhS with LV reconstruction of a patient with LV aneurysm. The area of electrical "silence" (scar) is highlighted with grey color; the low-amplitude ventricular potential area of 0,5 mV – with red; the transient zone of 0,5 - 1,5 mV – with yellow-green; the zone of viable myocardium – with violet; the double potential zone – with blue dots and the zone of delayed potential – with pink dots. Front view, right oblique view. (original data)

Surgical ventricular reconstruction (SVR) was performed by the standard methods by V.Dor and in L.Menicanti modification. [4,6]. After cardiac arrest with a calculated injection of cardio‐ plegia solution (Kustodiol) there was performed grafting of distal coronary anastomoses. Left ventricle was opened with a longitudinal incision in the apical area to be parallel to the anterior descending artery along visually identified scarred tissue. After revision of left ventricular cav‐ ity thrombotic mass if any was eliminated. In case of endocardectomy we performed resection of scarred and transient areas of LV. Residual volume of LV cavity was calculated by a physio‐ logical norm of 50-60 ml/m2 of a patient's body surface, and was limited by a special sizer (Chase Medical Richardson, TX, USA). To close LV cavity we used an endocardial synthetic patch (Gore-tex). When L. Menicanti modification was applied, LV neoapex was formed with one or two u-shaped sutures. LV was closed with a double running suture [11,12].

Endocardectomy was performed in 84 patients who were referred to the study group (LVR +EE); on average there was dissected 44cm2 of LV endocardium (from 17 to 84 cm2 ) includ‐ ing ventricular septum. The control group consisted of 104 patients in which endocardial re‐ section was not performed (LVR without EE). The patients were allocated into the groups randomly. All the patients signed the informed consent form. The study was approved by the local ethic committee.

Resection of aneurysm and left ventricular reconstruction (LVR) was performed by V. Dor procedure in 130 patients, by L. Menicanti modification - in 58 patients. In 29 patients from both groups mitral valve fibrous ring repair was done. All the patients underwent coronary artery bypass grafting (CABG). The area of an endocardial synthetic patch varied from 5 to 20 cm2 . Clinical data and the data of instrumental examinations did not show significant dif‐ ferences between the patient groups (Table 1).


**Table 1.** Clinical characteristics of the patients.

**Figure 3.** Patient T, 56 year old. Before the surgery. EPhS with LV reconstruction of a patient with LV aneurysm. The area of electrical "silence" (scar) is highlighted with grey color; the low-amplitude ventricular potential area of 0,5 mV – with red; the transient zone of 0,5 - 1,5 mV – with yellow-green; the zone of viable myocardium – with violet; the double potential zone – with blue dots and the zone of delayed potential – with pink dots. Front view, right oblique

Surgical ventricular reconstruction (SVR) was performed by the standard methods by V.Dor and in L.Menicanti modification. [4,6]. After cardiac arrest with a calculated injection of cardio‐ plegia solution (Kustodiol) there was performed grafting of distal coronary anastomoses. Left ventricle was opened with a longitudinal incision in the apical area to be parallel to the anterior descending artery along visually identified scarred tissue. After revision of left ventricular cav‐ ity thrombotic mass if any was eliminated. In case of endocardectomy we performed resection of scarred and transient areas of LV. Residual volume of LV cavity was calculated by a physio‐ logical norm of 50-60 ml/m2 of a patient's body surface, and was limited by a special sizer (Chase Medical Richardson, TX, USA). To close LV cavity we used an endocardial synthetic patch (Gore-tex). When L. Menicanti modification was applied, LV neoapex was formed with

Endocardectomy was performed in 84 patients who were referred to the study group (LVR

ing ventricular septum. The control group consisted of 104 patients in which endocardial re‐ section was not performed (LVR without EE). The patients were allocated into the groups randomly. All the patients signed the informed consent form. The study was approved by

Resection of aneurysm and left ventricular reconstruction (LVR) was performed by V. Dor procedure in 130 patients, by L. Menicanti modification - in 58 patients. In 29 patients from both groups mitral valve fibrous ring repair was done. All the patients underwent coronary artery bypass grafting (CABG). The area of an endocardial synthetic patch varied from 5 to

. Clinical data and the data of instrumental examinations did not show significant dif‐

of LV endocardium (from 17 to 84 cm2

) includ‐

one or two u-shaped sutures. LV was closed with a double running suture [11,12].

+EE); on average there was dissected 44cm2

ferences between the patient groups (Table 1).

the local ethic committee.

20 cm2

view. (original data)

324 Principles and Practice of Cardiothoracic Surgery

SSPS 11.5 for Windows software was used for the analysis. Shapiro-Wilk test was applied to assess normality of distribution law of quantitative values. The parameters conforming with the normal distribution test were described with the use of a mean value (M) and a standard deviation (SD). Qualitative data were described by the rate of occurrence or its percentage. Student's t-test was used to evaluate significance of the differences of quantitative values in the compared groups when distribution law was normal. To see the significance of differen‐ ces among quantitative values Z criterion (Fisher's exact test) was used. Evaluation of signif‐ icance of differences in postoperative mortality was carried out by Kaplan-Meier method. With p<0.05 all the statistical parameters were considered significant.
