Surgical ventricular restoration by means of Dor procedure is a surgical option in patients with coronary artery disease and post infarcular left ventricular aneurysm. This procedure gives a better outcome in those patients with poor left ventricular ejection fraction. Traditional cardiac surgical methods may have limited benefits in these types of patients. The Dor procedure excludes akinetic or dyskinetic portion of the anterior wall and septum, reshapes the LV with a stitch that encircles the transitional zone between normal contractile myocardium and aneurysmal scar tissue, and uses a patch to reestablish ventricular wall contour. By this technique, LV size and geometry is improved, reduces wall tension and enhances overall systolic function. Coronary bypass surgery is almost always performed with this procedure.
A 52-year-old American national was referred to cardiac surgery from outside the country with class IV symptoms. He was getting treatment for his hypertension and diabetes mellitus. His coronary angiogram showed left main stem stenosis and total occlusion of the LAD. Echocardiogram showed left ventricular aneurysm with LV clot, and no mitral regurgitation. His LV ejection fraction was 20%. He was scheduled for Dor procedure and CABG.
Surgical Procedure
Under cardiopulmonary bypass and cardioplegic arrest, the aneurysm was incised parallel to the LAD and clots were removed. A purse-string suture using 2-0 prolene was placed around the circumference of the scar at the transitional zone and tied down to determine size of the new ventricular opening. A Gore-tex patch was then sutured to the ventricular opening with interrupted 2-0 prolene suture. A second layer of continuous suture using 2-0 prolene is done. The edges of the ventricular free wall were then closed over the patch with a running 2-0 prolene supported with Teflon felt. The distal coronary anastomosis was done by saphenous vein to diagonal 1 and obtuse marginal 1. Left internal mammary was anastomosed to the proximal LAD. Proximal anastomosis was done to the ascending aorta with a side biting clamp. The patient was then weaned from CPB in a standard fashion. TEE was used to assess filling contractility and mitral valve function. He was electively put on IABP. Postoperative TEE showed improved LV contractility.
Discussion
The operative goal of the Dor procedure is to achieve complete coronary revascularization, reduce LV volume and restore its shape. The Dor procedure improves quality of life and survival in patients with left ventricular aneurysm. Also , complete revascularization is mandatory for a good outcome.
