What is the recommended treatment for a patient with a symptomatic or large aneurysm, specifically regarding Endoaneurysmorrhaphy (endoaneurysm repair)?

Endoaneurysmorrhaphy: Treatment Recommendations

Overview

Endoaneurysmorrhaphy is the procedure of choice for symptomatic left ventricular aneurysms, offering low perioperative mortality (5-5.7%), significant improvement in functional status, and excellent medium-term survival rates. 1, 2

This surgical technique involves opening the aneurysm sac and reconstructing the ventricular chamber from within, as opposed to simple exclusion or resection approaches.

Clinical Indications

Symptomatic Left Ventricular Aneurysms

• Endoaneurysmorrhaphy should be performed for all symptomatic ventricular aneurysms, particularly in patients with heart failure symptoms (NYHA class III or higher). 2
• The procedure results in significant amelioration of cardiac clinical status, with median NYHA class improving from III preoperatively to II postoperatively (p < 0.001). 2

Location Considerations

• Anterior-septal left ventricular aneurysms are the most common indication and carry lower surgical risk. 1
• Posterior left ventricular aneurysms can be treated with endoaneurysmorrhaphy but carry higher perioperative mortality (p=0.017), likely due to more severe baseline heart failure and larger ventricular volumes. 1
• Patients with posterior aneurysms present with higher LV end-diastolic volume index (138±38 vs. 102±41 ml/kg; p=0.040) compared to anterior-septal locations. 1

Surgical Outcomes and Prognosis

Short-Term Results

• Perioperative mortality ranges from 5.0% to 5.7%, which is acceptably low for this high-risk population. 1, 2
• Concomitant mitral valve surgery (p=0.008) and prolonged extracorporeal circulation time (p=0.001) are significant predictors of higher perioperative mortality. 1

Medium to Long-Term Outcomes

• Annual mortality during follow-up is 3.3% per year, with 5-year survival rate of 78%. 2
• Preexisting arterial occlusive disease and advanced age (>70 years) are significant predictors of medium-term mortality on multivariate analysis. 2
• Implantation of the left internal mammary artery during concomitant coronary revascularization is associated with better survival rates. 2

Critical Technical Considerations

Superiority Over Exclusion Techniques

• Endoaneurysmorrhaphy is recommended over simple ligation and exclusion when technically feasible. 3
• Excluded aneurysms without resection frequently expand over time: 32% increase in size (mean 5.9 mm), 20% remain unchanged, and only 48% decrease in size during follow-up. 3
• Contrast enhancement (analogous to type II endoleak) occurs in 44% of excluded aneurysm sacs, potentially leading to continued expansion and symptoms. 3

Surgical Approach

• Complete aneurysm excision or endoaneurysmorrhaphy should be performed rather than simple exclusion to prevent late complications including continued expansion and potential rupture. 3
• The technique involves opening the aneurysm sac, removing thrombus, and reconstructing the ventricular geometry from within using endocardial sutures. 2

Patient Selection Algorithm

Favorable Candidates

• Symptomatic patients with NYHA class II-IV heart failure 2
• Age <70 years (better medium-term survival) 2
• Absence of severe peripheral arterial occlusive disease 2
• Anterior-septal aneurysm location (lower surgical risk) 1

Higher Risk Patients (Requires Careful Individualized Assessment)

• Age >70 years (significant predictor of mortality) 2
• Posterior LV aneurysm location (higher perioperative mortality) 1
• Severe heart failure with markedly elevated LV end-diastolic volumes 1
• Need for concomitant mitral valve surgery (p=0.008 for mortality) 1

Important Caveats

• The presence of a posterior LV aneurysm is independently associated with higher perioperative mortality, though this may be confounded by more severe baseline heart failure in these patients. 1
• Concomitant coronary revascularization with internal mammary artery grafting should be performed when indicated, as it improves long-term survival. 2
• Simple exclusion without resection is inadequate and leads to continued aneurysm expansion in one-third of cases, similar to endotension after endovascular aortic repair. 3