AKINETIC VERSUS DYSKINETIC POSTINFARCTION SCAR - RELATION TO SURGICALOUTCOME IN PATIENTS UNDERGOING ENDOVENTRICULAR CIRCULAR PATCH PLASTY REPAIR

Objectives. This retrospective study attempted to relate surgical outc ome with the extent and type of preoperative wall motion asynergy in p atients with postinfarction myocardial scar who underwent endoventricu lar circular patch plasty repair and associated coronary grafting. Bac kground. Left ventricular (LV) pump function improvement is difficult to predict after aneurysmectomy, for either akinetic or dyskinetic sca r, and previous studies have reported that the absence of paradoxic sy stolic motion correlates with higher operative mortality and no improv ement in pump function. Methods. Two hundred forty-five patients who u nderwent endoventricular circular patch plasty repair and associated c oronary grafting were retrospectively selected if they had technically adequate right and left anterior LV angiograms before the operation, All had right and left cardiac catheterization, The centerline method was applied to preoperative right anterior oblique LV angiography to a ssess the absolute motion of the chords and the percent length of the perimeter showing a fractional shortening <2 SD from the normal mean v alue (extent of asynergy ([A%]). Results. The overall perioperative mo rtality rate was 6%; 120 patients had akinetic and 125 had dyskinetic scar, and no differences were found among the groups in terms of all t he clinical and hemodynamic variables collected in the study. Patients with a large scar (A% >60), either akinetic or dyskinetic, had a high er perioperative mortality rate (12%) than patients with a small scar (2.2%), After the operation, the ejection fraction (EP) increased from 36 +/- 13% to 50 +/- 13% (mean +/- SD), and pulmonary pressures signi ficantly decreased, End-diastolic volume decreased from 199 +/- 75 to 89 +/- 36 ml/m(2). Patients with a large akinetic scar had the most se verely impaired preoperative function (largest ventricular volumes and highest pulmonary mean pressure); nevertheless, they had an impressiv e improvement in function (EF from 25 +/- 9% to 41 +/- 12%), not diffe rent from that observed with large dyskinetic scarring (EF from 26 +/- 7% to 46 +/- 11%). Conclusions. Surgical outcome of endoventricular c ircular patch plasty repair for postinfarction myocardial scar relates to the extent of LV asynergy rather than to the presence or absence o f dyskinesia, Patients with a large akinetic scar and severely depress ed pump function benefit from a relatively simple surgical procedure p reviously reserved only for dyskinetic aneurysm. The reduction of wall tension and oxygen demand, owing to the marked decrease of volumes, a nd the increase in oxygen supply, owing to revascularization, may play a major role in improving pump function. (C) 1997 by the American Col lege of Cardiology.