27. Repair of Post-Infarction Ventricular Aneurysm (DOR Endoventricular Circular Patch Plasty (EVCPP))

Shane P. Smith, MD and Daniel J. Beckman, MD
University of Indiana, Indianapolis, IN, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by James H. Neel, MD and Mark S. Slaughter, MD.

Essential Operative Steps
Note: Steps 1-14 are part of the CABG portion of the procedure

  1. Lines and monitoring
  2. General endotracheal anesthesia
  3. Intraoperative TEE
  4. Median sternotomy
  5. Conduit choice
  6. Pericardiotomy, pericardial well creation, and assessment of the ascending aorta for cannulation, anastomotic sites, etc
  7. Heparinization (400 u/kg)
  8. Arterial/venous cannulation (± LV vent)
  9. Cardioplegia cannula placement (antegrade ± retrograde)
  10. Confirmation of ACT (> 400 seconds)
  11. Commencement of CPB
  12. Aortic crossclamp
  13. Cardioplegia (antegrade, topical, retrograde)
  14. Distal anastomoses (proximal anastomoses to be performed after EVCPP)
  15. (Proceeding with Dor procedure)
  16. Ventriculotomy (into depressed aneurysmal portion of ventricular wall)
  17. Removal of thrombus
  18. ± cryotherapy for VT therapy (if indicated)
  19. Mitral repair/replacement (if indicated)
  20. Purse string suture at margin of normal fibrous muscle (2-0 non-absorbable monofilament)
  21. LV sizing with balloon device (approximately 40-50 ml/kg)
  22. Placement of patch (Gore-Tex, Dacron, autologous, heterologous) at “neck”, secured with running 3-0 or 4-0
    monofilament
  23. Oversewing/resection of excess aneurysmal ventricular free wall
  24. (Back to CABG procedure)
  25. LIMA-LAD anastomosis
  26. Proximal anastomoses
  27. Warm antegrade blood cardioplegia (“Hot Shot”)
  28. Deairing maneuvers
  29. Removal of aortic crossclamp
  30. Assessment of hemostasis
  31. CPB weaning
  32. Protamine administration
  33. Placement of atrial/ventricular wires
  34. Chest tube placement
  35. Venous decannulation
  36. Aortic decannulation
  37. Repeated hemostasis assessment
  38. Sternotomy closure

Potential Complications and Pitfalls

  1. Air embolism (ineffective/inadequate deairing maneuvers): Use of an LV vent, aortic root vent, and carbon dioxide on
    the field will help decrease the risk of air embolism
  2. Poor hemostasis: Use of hemostatic agents on the LV suture line such as Bioglue or CoSeal can decrease suture line
    bleeding. A felt strip used on both sides of the ventriculotomy closure can also improve hemostasis and provide better
    tissue approximation
  3. Arrhythmias: Cryotherapy applied to the resection margin at the border of viable myocardium and endocardial scar can
    decrease ventricular arrhythmias
  4. Coronary Artery Injury: Ensure entrance point for ventriculotomy is at least 1.5-2 cm from the LAD
  5. Dehiscence or bleeding from ventriculotomy repair: Adequate resection of the endocardial scar must be done to prevent
    dehiscence from weak native heart tissue
  6. Low cardiac output from small residual LV volume: Assessing LV volume with a balloon device such as a foley catheter
    can help in visualization of volume reduction and prevent undersizing
  7. Mitral valve insufficiency: Patients with a dilated mitral valve annulus and insufficiency can undergo repair of the mitral
    valve through the ventriculotomy using an Alfieri stitch

Template Dictation
Preoperative Diagnosis: [INDICATION: CAD with post-infarction LV aneurysm, ventricular akinesia]
Postoperative diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Coronary artery bypass grafting [DETAILS: LIMA-LAD, SVG targets, etc.] with
endoventricular circular patch plasty (EVCPP) and endoscopic vein harvest (EVH)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT]. Patient was found on
preoperative echocardiography to have an akinetic [OR] dyskinetic wall segment following a transmural anterior wall
myocardial infarct, concerning for ventricular aneurysm [DETAILS]. Preoperative angiography revealed [FINDINGS].
Description of the Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were confirmed. The patient was placed on the operating room table in the supine position. General endotracheal
anesthesia was induced per the anesthesia team. Arterial line(s) and central venous access were obtained [DETAILS: location,
type of access, etc]. Pulmonary artery catheter was also placed. Preoperative TEE was performed to evaluate cardiac function,
valve function, and aneurysmal dimensions/characteristics. The patient was then prepped and draped in the standard surgical
fashion with all bony prominences padded appropriately. A pre-incisional timeout was performed.
Median sternotomy was performed. Simultaneously to this, the saphenous vein conduit was harvested from the [right/left
leg] utilizing an [open/endoscopic] technique. Upon gaining entrance into the chest, the IMA retractor was placed in the chest
and the LIMA was harvested utilizing a pedicled technique. The LIMA bed was then examined and confirmed to be
hemostatic. CPB tubing was brought up onto the field and passed off to perfusion in the standard fashion. At this point, the
pericardial well was established by incising the anterior pericardium utilizing electrocautery and tacking the pericardial edges
up to the chest wall. Care was taken to avoid injury to the innominate vein. Aortic cannulation stitches were placed in the
ascending aorta below the innominate artery takeoff. Right atrial cannulation stitches were next placed. The patient was then
fully heparinized per anesthesia staff. The aortic cannula was inserted into the aorta, secured, deaired, and attached to the CPB
arterial tubing. The venous cannula was inserted into the right atrium, secured, and attached to the venous CPB tubing in the
standard fashion. An aortic root vent was then placed into the ascending aorta below the level of the proposed site of crossclamp
application. The vent was secured with prolene suture and connected to the vent/cardioplegia tubing. CPB was initiated and
proper flows confirmed with the perfusion team. Aortic crossclamp was placed and [total volume]ml antegrade cardioplegia
was administered causing rapid arrest of cardiac function.
Next, attention was turned to identifying suitable targets on distal coronary arteries [specify sites/targets]. Arteriotomy was
performed in the standard fashion. The SVG was trimmed and spatulated to the appropriate size to match the arteriotomy. The
SVG graft anastomosis was performed with running 7-0 prolene suture in the standard end-to-side fashion. Antegrade flow
through the anastomosis was checked and hemostasis was confirmed. [Repeat for subsequent SVG target sites.] Following
SVG anastomoses, a suitable site on the LAD [specify target site] was confirmed and the artery opened. The LIMA was
prepared, trimmed to the appropriate length, and spatulated to match the arteriotomy on the LAD. The anastomosis was
performed in the usual end-to-side manner utilizing a running 7-0 prolene. The bulldog clamp was removed briefly to ensure
forward flow through the anastomosis and check for hemostasis.
Following completion of the distal anastomoses, attention was turned to the ventricular aneurysm. The heart was decompressed,
and the area of ventricular wall defect was confirmed. A longitudinal ventriculotomy was performed utilizing a #15 scalpel
blade and lengthened encompassing the full extent of the defect. Care was taken to avoid injury to the surrounding coronary
vessels by ensuring that the entrance point was at least 2cm from the LAD. All visualized thrombus was removed from the left
ventricle. The endocardial scar was resected sharply. Cryotherapy was applied to the edge of the resection at the border of
viable myocardium and scar to prevent ventricular tachyarrhythmia.
Next, a 2-0 prolene purse string suture was passed along the surrounding border of the defect at the level of the junction of
normal and fibrous ventricular muscle. Appropriate ventricular volume was assessed with a foley catheter balloon and the
pursestring was tied down. Next, a piece of [Gore-Tex, Dacron, autologous, or heterologous] graft was selected and trimmed
to the size of the remaining defect. The graft was secured in place over the defect utilizing interrupted mattress sutures of 3-0
prolene placed through the edges of the patch and then transmurally from the endocardium to the epicardium at the level of the
pursestring and then tied over a pledget. The extraneous ventricular free wall musculature was then re-approximated, folded,
and oversewn covering the defect utilizing 3-0 prolene suture in a running mattress with felt strips on each side cut to the size
of the ventriculotomy and reinforced with a continuous running suture of 3-0 polypropylene.
Attention was then turned to the proximal aorta. The [specify graft target] SVG was brought up to the proposed site of
proximal anastomosis and measured to ensure appropriate length. The vein graft was then trimmed to the correct length and
the end was spatulated in the standard fashion. The site for proximal anastomosis was selected and an aortotomy was performed

utilizing an aortic punch. The proximal anastomosis was performed utilizing a running 5-0 prolene in the standard end-to-side
fashion. [Repeat for each proximal SVG anastomosis].
Upon completion of the proximal anastomoses, a dose of warm blood (“Hot Shot”) cardioplegia was administered and the
patient was rewarmed. Deairing maneuvers were performed. The bulldog clamp was removed from the LIMA and the LIMALAD anastomosis was rechecked to ensure adequate flow and hemostasis. The aortic crossclamp was removed and the aorta
was further deaired utilizing the aortic root vent. Chest tubes were then placed [specify number and location]. Pacing wires
were then inserted, secured, and tested for appropriate capture. TEE was used to reevaluate left ventricle contractility and mitral
valve function. TEE was also utilized to confirm adequateness of deairing; the aortic root vent was removed, and sutures were
secured. The patient was weaned from CPB. The venous cannula was removed, and protamine was started for heparin reversal.
Once hemodynamic stability was assured, the aortic cannula was removed and both the venous and aortic pursestring sutures
were secured. Hemostasis was ensured at all sites within the mediastinum as well as the LIMA bed. The sternum was then
reapproximated utilizing stainless steel wires [SPECIFY NUMBER AND TYPE OF WIRE SUTURES]. The incision was
then irrigated copiously with saline solution. The fascia was then closed with running 0 PDS followed by running 2-0 PDS for
the deep dermal layer. Skin was approximated with running 3-0 monocryl suture. Sterile dressings were applied. Chest tubes
were connected to atrium drainage canisters.


All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the surgical procedure. The patient
was subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.

Multiple Choice Question(s)
A patient with an ischemic left ventricular aneurysm had ventricular tachyarrhythmia prior to surgical intervention, how should
this be addressed in the OR?
A. Full Cox Maze IV
B. Left Atrial Appendage Clip
C. Cryotherapy to the border of the endocardial scar and viable myocardium
D. Pulmonary Vein Isolation
E. Utilization of an autologous patch for aneurysm repair
Answer: C. In patients presenting with recurrent ventricular tachycardia and a calcified aneurysm, subendocardial resection of
the scar tissue and cryoablation at the level of the transitional zone can be performed with good results

Sources
Shanmugam G, Ali IS. Surgical Ventricular Restoration: An Operation to Reverse Remodeling-Clinical Application (Part II).
Current Cardiology Reviews. 2009;5:350-359.
Dor V, Saab M, Coste P, Kornaszeska M, Montiglio F. Left Ventricular Aneurysm: A New Surgical Approach. Thoracic and
Cardiovascular Surgery . 1989;37:11-19.
McCarthy PM, Caldeira C. Modified Endoventricular Circular Plasty (Dor procedure). CTSNet. Published online 2008:1-6.
https://www.ctsnet.org/print/article/modified-endoventricular-circular-plasty-dor-procedure
Dor V, Sabatier M, Donato M di, Montiglio F, Toso A, Maioli M. Efficacy of endoventricular patch plasty in large
postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars. The
Journal of Thoracic and Cardiovascular Surgery. 1998;116(1):50-59.

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