Surgical Ventricular Restoration  with the Dor Procedure for Anterior LV Aneurysm and Suspected Rupture: A Case Report

Surgical Ventricular Restoration with the Dor Procedure for Anterior LV Aneurysm and Suspected Rupture: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical Ventricular Restoration with the Dor Procedure for Anterior LV Aneurysm and Suspected Rupture: A Case Report Georgios Seretakis, Nikoleta Stanitsa, Emmanouel Tempelis, Mehmet Cilasin, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6505699/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Surgical ventricular restoration (SVR) using the Dor procedure has become increasingly rare in the era of modern revascularization and improved medical management of myocardial infarction. However, in selected patients with severe left ventricular (LV) remodeling or suspected rupture, it remains a critical surgical option. Case Presentation: A 55-year-old male presented with acute chest pain and dyspnea. Imaging revealed an extensive anterior LV aneurysm with suspected contained rupture. After successful LAD revascularization, the patient underwent SVR using the Dor procedure. Intraoperative findings confirmed a large thrombus and dyskinetic segments, which were excluded using a Dacron patch. Postoperative recovery was uneventful. Outcome: At four-year follow-up, the patient remains asymptomatic with preserved LV function and no signs of recurrence. Conclusion: This case illustrates that the Dor procedure remains a valuable life-saving strategy in select patients with post-infarction LV aneurysms and suspected rupture, particularly when rapid diagnosis and timely surgical intervention are achieved. Dor procedure surgical ventricular restoration left ventricular aneurysm myocardial infarction ventricular rupture cardiac surgery endoventricular patch plasty Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Surgical Ventricular Restoration (SVR) is a surgical approach for ischemic cardiomyopathy that attempts to exclude non-contributive myocardial segments, restore LV geometry closer to normal, and improve LV function. As described by Dor in the 1980s, the technique incorporates endoventricular patch rearrangement to improve chamber contours, lower wall stress, hypertrophy, and heart failure symptoms [1, 2]. The emerging practice of aggressive early revascularization—especially percutaneous coronary interventions (PCI)—combined with more effective medical management has reduced the post-infarction aneurysm formation incidence. Furthermore, the STICH trial effectively disenfranchised the routine SVR strategy by showing no survival benefit when added to CABG for choicemaker patients [3]. Consequently, the procedure is less frequently performed nowadays in cardiac surgical practice. Nonetheless, in patients with discrete preserved basal function, ruptured aneurysms, or other basal related complications, SVR especially the Dor procedure may be offered as a last resort life-saving procedure. In such cases, timely surgical care can avert death and reduce symptoms in a significant and sustainable manner [4, 5]. This report presents a rare and successful case of SVR using the Dor procedure in a patient with a large anterior LV aneurysm and suspected contained rupture, demonstrating excellent four-year follow-up with preserved ventricular function. Case Presentation: A 55-year-old male was brought to the emergency room on December 6, experiencing acute chest pain and shortness of breath. He noted an episode of discomfort in the chest area accompanied by vomiting a month prior, but self-treated, which delayed seeking medical help. His medical history was remarkable for severe smoking (>50 pack-years) and no known cardiovascular illnesses or previous surgeries. At the onset of the treatment, the patient was tachypneic, but hemodynamic parameters were stable. An ECG showed q-waves with ST-segment elevations in V2–V6, II, III and aVF leads suggestive of extensive anterolateral and inferoapical myocardial infarction. Cardiac enzymes were also elevated in laboratory studies. Transthoracic echocardiography showed an advanced level of LV dysfunction characterized by dyskinesia of the apex and mid-ventricular segments with an estimated ejection fraction of 20-–25%. Right ventricular function was preserved along with mild to moderate mitral regurgitation. Coronary angiography demonstrated complete occlusion of the left anterior descending (LAD) artery and significant stenosis in the distal left circumflex (LCx) artery beyond the first obtuse marginal branch(Figure 1). The patient underwent successful PCI of the LAD with implantation of two drug-eluting stents. Given persistent hemodynamic compromise and the echocardiographic findings, further evaluation with ECG-gated contrast-enhanced CT was performed. This revealed left ventricular dilation, wall thinning, and contrast pooling within the LV wall—suggestive of a contained rupture(Figure 2). Hemorrhagic components were also present within the suspected rupture zone. The patient was urgently transferred to the cardiothoracic surgery unit for surgical evaluation and definitive management. Surgical Technique The patient underwent surgery under general anesthesia with endotracheal intubation. Transesophageal echocardiography (TOE) was used intraoperatively for continuous cardiac evaluation. An intra-aortic balloon pump (IABP) was placed preoperatively for hemodynamic support. Following systemic heparinization, cardiopulmonary bypass was established via right transaxillary arterial cannulation and right transfemoral venous cannulation through a median sternotomy. Step 1: Aneurysm Identification The aneurysmal segment of the anterior left ventricular wall was identified following exposure through median sternotomy and adhesiolysis. Visualization was aided by intraoperative TOE and direct palpation, allowing accurate delineation of the diseased myocardium. Step 2: Aneurysm Entry The incision point was selected approximately 1.5 to 2.0 cm lateral to the left anterior descending (LAD) artery, toward the left ventricular free wall, ensuring access through a relatively stable margin of the aneurysmal segment. Step 3: Cavity Inspection and Thrombus Evacuation The cavity of the left ventricle was carefully examined for structural integrity and thrombotic material. A large, laminated thrombus was identified and completely extracted (Figure 3). Visual inspection and palpation were used to delineate the boundary between aneurysmal scar tissue and viable, contracting myocardium, which guided the subsequent repair steps. The gross specimen of the thrombus was also examined (Figure 4). Step 4: Ventricular Sizing and Purse-String Suturing A balloon catheter was inserted into the left ventricular cavity to assist with sizing and to maintain physiological shape during repair. A Fontan-style purse-string suture using 2-0 polypropylene was placed around the aneurysm opening. In cases where the opening exceeded 3 cm, a second concentric purse-string suture was placed approximately 4 mm distal to the first. Step 5: Patch Preparation and Placement Following adequate sizing, the balloon was removed from the ventricular cavity. A Dacron patch was then measured and tailored according to the internal dimensions of the cavity (Figure 5). Step 6: Patch Fixation and Reinforcement After proper shaping, the Dacron patch was secured to the endocardial surface using a continuous 0 Prolene suture. Teflon PTFE felt strips were used to reinforce the suture line, and the ventricular wall was then closed over the patch to re-establish physiologic chamber geometry (Figure 6). The Dor procedure is schematically illustrated in six steps (Figure 7). The patient was successfully weaned from cardiopulmonary bypass and transferred to the intensive care unit in stable condition. Postoperative Course and Follow-Up The patient had an uneventful recovery. He was extubated within hours and weaned off inotropes by postoperative day two. Postoperative echocardiography demonstrated significant improvement in ventricular geometry, with resolution of the dyskinetic segments and improved systolic function. The patient was discharged on optimal medical therapy including dual antiplatelet therapy, beta-blockers, ACE inhibitors, and diuretics. At four-year follow-up, he remains asymptomatic, in NYHA Class I, with preserved LV systolic function and no evidence of recurrent aneurysm or thrombus on serial imaging. Discussion Although SVR was once widely performed, its use has declined significantly in the current era due to earlier detection of myocardial infarction and the widespread availability of percutaneous coronary intervention (PCI) and optimized medical therapy [2]. As a result, fewer patients progress to the chronic remodeling phase that previously made them surgical candidates. Nevertheless, SVR remains a valuable option in specific cases, particularly those involving large dyskinetic aneurysms or suspected left ventricular rupture, where medical therapy alone may not suffice. The Dor procedure, first described in 1985, involves aneurysm resection, thrombus removal, and endoventricular patch plasty to exclude the scarred myocardium and restore left ventricular geometry [3]. This technique has been shown to improve symptoms, reduce LV volume, and in some series, improve long-term survival [4]. In this report, we present the case of a 55-year-old male with a history of untreated myocardial infarction who developed a large anterior LV aneurysm with suspected contained rupture. The patient underwent urgent surgical intervention using the Dor procedure, resulting in a successful recovery and excellent long-term outcome. This case highlights the relevance of SVR in contemporary practice and offers insight into the management of complex ischemic ventricular remodeling. Discussion Although surgical ventricular restoration (SVR), particularly the Dor procedure, is no longer routine in the era of percutaneous coronary intervention (PCI), it remains a critical option in select cases of severe ischemic left ventricular (LV) remodeling, especially when complicated by aneurysm or suspected rupture [1,2]. This case highlights how the Dor procedure can offer a life-saving solution in a hemodynamically vulnerable patient with extensive anterior wall dysfunction. SVR aims to restore ventricular geometry, reduce wall stress, and eliminate non-functional myocardium, thereby improving overall cardiac function [3,4]. Our patient presented with imaging findings highly suspicious for contained LV rupture—a condition associated with significant mortality if left untreated. Prompt identification and timely surgical intervention allowed for successful aneurysm exclusion and restoration of ventricular architecture, with preservation of long-term function. While the STICH trial (Surgical Treatment for Ischemic Heart Failure) reported no overall survival benefit from adding SVR to CABG in a broad cohort, subgroup analyses suggest benefit in highly selected patients—particularly those with discrete aneurysmal segments and preserved basal contractility [5]. Further, the STICHES extension trial showed that long-term survival with CABG is improved over medical therapy alone, supporting aggressive surgical approaches in ischemic cardiomyopathy [6]. In this context, our patient, with a localized, severely dyskinetic aneurysm and suspected rupture, fits the profile of those most likely to benefit from SVR. Technical success in SVR depends on several key steps: accurate preoperative imaging, complete thrombus evacuation, careful delineation of viable myocardium, and precise patch tailoring to optimize LV geometry. In our case, the combination of transthoracic echocardiography, ECG-gated CT, and intraoperative transesophageal echocardiography (TOE) enabled comprehensive assessment of the aneurysm. The use of an intra-aortic balloon pump (IABP) preoperatively provided hemodynamic support and likely contributed to the stable postoperative course. Although SVR is rarely performed today, long-term studies from Dor and others have demonstrated durable outcomes in terms of functional improvement and survival, particularly when the procedure is performed in experienced centers and appropriately selected patients [1,3,7]. This case reinforces that message: even in the modern PCI era, surgical solutions have an important place in complex ischemic heart disease. Conclusion This case highlights that surgical ventricular restoration using the Dor procedure remains a highly effective, though underutilized, intervention for selected patients with ischemic left ventricular aneurysms—particularly when complicated by suspected rupture. In the setting of localized, non-contractile myocardium and hemodynamic compromise, timely surgical intervention can restore ventricular geometry, prevent catastrophic progression, and significantly improve long-term functional outcomes. Despite the modern dominance of percutaneous interventions and optimized medical therapy, this case reaffirms the enduring relevance of surgical techniques such as the Dor procedure. When performed with meticulous planning and patient selection, SVR can provide durable survival and symptomatic relief, even years after myocardial infarction. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for the publication of this case report and all accompanying images. All images included in the manuscript are original and were obtained during the clinical management of the patient. The signed consent form is available upon request. Funding The authors received no specific funding for this case report. References Dor V, Sabatier M, Montiglio F, Civaia F, Di Donato M. Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience. Semin Thorac Cardiovasc Surg. 2001;13(4):435–47. Athanasuleas CL, Buckberg GD, Stanley AW, Siler W, Dor V, Di Donato M, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the treatment of dilated ischemic cardiomyopathy. J Am Coll Cardiol. 2004;44(5):973–9. Menicanti L, Castelvecchio S, Ranucci M, Frigiola A, Santambrogio C, De Vita C, et al. The Dor procedure in ischemic cardiomyopathy: long-term results of the surgical treatment of ischemic heart failure study. Ann Thorac Surg. 2007;84(6):2052–60. Jatene AD. Left ventricular geometric reconstruction in the treatment of heart failure. Arq Bras Cardiol. 2002;78(2):193–8. Jones RH, Velazquez EJ, Michler RE, Sopko G, Oh JK, O’Connor CM, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med. 2009;360(17):1705–17. Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374(16):1511–20. Di Donato M, Sabatier M, Dor V, Toso A, Barletta GA. Surgical ventricular restoration: left ventricular shape influence on cardiac function, clinical status, and survival. Ann Thorac Surg. 2002;74(5):1471–6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6505699","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":449551311,"identity":"12e051ed-4e28-477c-a077-58b410573909","order_by":0,"name":"Georgios Seretakis","email":"","orcid":"","institution":"Evangelismos Hospital","correspondingAuthor":false,"prefix":"","firstName":"Georgios","middleName":"","lastName":"Seretakis","suffix":""},{"id":449551312,"identity":"eacb5beb-4ecc-4394-ab9e-b445ce7bd4ec","order_by":1,"name":"Nikoleta 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15:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6505699/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6505699/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82151354,"identity":"0cbf581b-3273-49ef-b8a7-f51b955790e0","added_by":"auto","created_at":"2025-05-07 07:20:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":202078,"visible":true,"origin":"","legend":"\u003cp\u003eDiagnostic coronary angiography demonstrating complete proximal occlusion of the left anterior descending (LAD) artery with absence of distal runoff, consistent with subacute or chronic total occlusion.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/25db5ae5114398ecb7945e0d.png"},{"id":82153875,"identity":"aadf9c3a-2ed9-40ff-801e-ac4d00c6b908","added_by":"auto","created_at":"2025-05-07 07:28:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":144007,"visible":true,"origin":"","legend":"\u003cp\u003eECG-gated contrast-enhanced CT scan showing marked thinning of the anterior wall of the left ventricle with intramyocardial contrast pooling, highly suggestive of a contained myocardial rupture.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/3a360dcd7650730e82ec3bfc.png"},{"id":82149965,"identity":"ba50ee42-72e4-4d22-ac05-7a5ea84a575a","added_by":"auto","created_at":"2025-05-07 07:12:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":973548,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative view of the opened left ventricular aneurysmal cavity revealing extensive laminated thrombus adherent to the endocardial surface.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/c6aa40c8a9662e630ad2aac0.png"},{"id":82149959,"identity":"106beb92-2ff3-4040-be4f-a0cb1fda6206","added_by":"auto","created_at":"2025-05-07 07:12:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":969950,"visible":true,"origin":"","legend":"\u003cp\u003eGross specimen of the organized laminated thrombus evacuated from the aneurysmal left ventricular cavity, demonstrating its multilayered structure.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/a0d9dd077f429c3dd8283e34.png"},{"id":82151356,"identity":"ece5c97c-67e1-4d62-9fe8-6220c6652482","added_by":"auto","created_at":"2025-05-07 07:20:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":629628,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative image showing the tailored Dacron patch positioned within the left ventricular cavity following thrombus evacuation and volume sizing.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/51a231cd0b9798650a1cb85a.png"},{"id":82149967,"identity":"ced08652-8b2a-4386-a877-25882a40817a","added_by":"auto","created_at":"2025-05-07 07:12:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":646417,"visible":true,"origin":"","legend":"\u003cp\u003eFinal stage of surgical ventricular restoration showing secure fixation of the Dacron patch with Prolene sutures and reinforcement using PTFE felt strips, followed by left ventricular wall closure.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/7a1cca26fdaebe0bd989b602.png"},{"id":82151357,"identity":"1e4e8912-bf05-4b66-91d1-74b5c9aae38e","added_by":"auto","created_at":"2025-05-07 07:20:33","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":602892,"visible":true,"origin":"","legend":"\u003cp\u003eComposite schematic illustration of the Dor procedure. Step 1: Identification of the aneurysmal segment. Step 2: Entry incision placed 1.5–2.0 cm lateral to the LAD artery. Step 3: Evacuation of laminated thrombus. Step 4: Balloon sizing and placement of Fontan-style purse-string sutures. Step 5: Tailoring and positioning of a Dacron patch. Step 6: Final patch fixation with PTFE felt reinforcement and closure of the left ventricular wall.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/afece81ad24e43e34037fc58.png"},{"id":100380052,"identity":"15fe0ef8-ea57-4c2f-9ec7-c151c6e9c8cd","added_by":"auto","created_at":"2026-01-16 10:16:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5959447,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6505699/v1/f2aa75dd-f00f-494d-96e0-9ceef5aefbe2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Ventricular Restoration with the Dor Procedure for Anterior LV Aneurysm and Suspected Rupture: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSurgical Ventricular Restoration (SVR) is a surgical approach for ischemic cardiomyopathy that attempts to exclude non-contributive myocardial segments, restore LV geometry closer to normal, and improve LV function. As described by Dor in the 1980s, the technique incorporates endoventricular patch rearrangement to improve chamber contours, lower wall stress, hypertrophy, and heart failure symptoms [1, 2].\u003c/p\u003e\n\u003cp\u003eThe emerging practice of aggressive early revascularization\u0026mdash;especially percutaneous coronary interventions (PCI)\u0026mdash;combined with more effective medical management has reduced the post-infarction aneurysm formation incidence. Furthermore, the STICH trial effectively disenfranchised the routine SVR strategy by showing no survival benefit when added to CABG for choicemaker patients [3]. Consequently, the procedure is less frequently performed nowadays in cardiac surgical practice.\u003c/p\u003e\n\u003cp\u003eNonetheless, in patients with discrete preserved basal function, ruptured aneurysms, or other basal related complications, SVR especially the Dor procedure may be offered as a last resort life-saving procedure. In such cases, timely surgical care can avert death and reduce symptoms in a significant and sustainable manner [4, 5].\u003c/p\u003e\n\u003cp\u003eThis report presents a rare and successful case of SVR using the Dor procedure in a patient with a large anterior LV aneurysm and suspected contained rupture, demonstrating excellent four-year follow-up with preserved ventricular function.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 55-year-old male was brought to the emergency room on December 6, experiencing acute chest pain and shortness of breath. He noted an episode of discomfort in the chest area accompanied by vomiting a month prior, but self-treated, which delayed seeking medical help. His medical history was remarkable for severe smoking (\u0026gt;50 pack-years) and no known cardiovascular illnesses or previous surgeries.\u003c/p\u003e\n\u003cp\u003eAt the onset of the treatment, the patient was tachypneic, but hemodynamic parameters were stable. An ECG showed q-waves with ST-segment elevations in V2\u0026ndash;V6, II, III and aVF leads suggestive of extensive anterolateral and inferoapical myocardial infarction. Cardiac enzymes were also elevated in laboratory studies.\u003c/p\u003e\n\u003cp\u003eTransthoracic echocardiography showed an advanced level of LV dysfunction characterized by dyskinesia of the apex and mid-ventricular segments with an estimated ejection fraction of 20-\u0026ndash;25%. Right ventricular function was preserved along with mild to moderate mitral regurgitation.\u003c/p\u003e\n\u003cp\u003eCoronary angiography demonstrated complete occlusion of the left anterior descending (LAD) artery and significant stenosis in the distal left circumflex (LCx) artery beyond the first obtuse marginal branch(Figure 1). The patient underwent successful PCI of the LAD with implantation of two drug-eluting stents.\u003c/p\u003e\n\u003cp\u003eGiven persistent hemodynamic compromise and the echocardiographic findings, further evaluation with ECG-gated contrast-enhanced CT was performed. This revealed left ventricular dilation, wall thinning, and contrast pooling within the LV wall\u0026mdash;suggestive of a contained rupture(Figure 2). Hemorrhagic components were also present within the suspected rupture zone.\u003c/p\u003e\n\u003cp\u003eThe patient was urgently transferred to the cardiothoracic surgery unit for surgical evaluation and definitive management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e The patient underwent surgery under general anesthesia with endotracheal intubation. Transesophageal echocardiography (TOE) was used intraoperatively for continuous cardiac evaluation. An intra-aortic balloon pump (IABP) was placed preoperatively for hemodynamic support. Following systemic heparinization, cardiopulmonary bypass was established via right transaxillary arterial cannulation and right transfemoral venous cannulation through a median sternotomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 1: Aneurysm Identification\u003c/strong\u003e The aneurysmal segment of the anterior left ventricular wall was identified following exposure through median sternotomy and adhesiolysis. Visualization was aided by intraoperative TOE and direct palpation, allowing accurate delineation of the diseased myocardium.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 2: Aneurysm Entry\u003c/strong\u003e The incision point was selected approximately 1.5 to 2.0 cm lateral to the left anterior descending (LAD) artery, toward the left ventricular free wall, ensuring access through a relatively stable margin of the aneurysmal segment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 3: Cavity Inspection and Thrombus Evacuation\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The cavity of the left ventricle was carefully examined for structural integrity and thrombotic material. A large, laminated thrombus was identified and completely extracted (Figure 3). Visual inspection and palpation were used to delineate the boundary between aneurysmal scar tissue and viable, contracting myocardium, which guided the subsequent repair steps. The gross specimen of the thrombus was also examined (Figure 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 4: Ventricular Sizing and Purse-String Suturing\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A balloon catheter was inserted into the left ventricular cavity to assist with sizing and to maintain physiological shape during repair. A Fontan-style purse-string suture using 2-0 polypropylene was placed around the aneurysm opening. In cases where the opening exceeded 3 cm, a second concentric purse-string suture was placed approximately 4 mm distal to the first.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 5: Patch Preparation and Placement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Following adequate sizing, the balloon was removed from the ventricular cavity. A Dacron patch was then measured and tailored according to the internal dimensions of the cavity (Figure 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStep 6: Patch Fixation and Reinforcement\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;After proper shaping, the Dacron patch was secured to the endocardial surface using a continuous 0 Prolene suture. Teflon PTFE felt strips were used to reinforce the suture line, and the ventricular wall was then closed over the patch to re-establish physiologic chamber geometry (Figure 6).\u003c/p\u003e\n\u003cp\u003eThe Dor procedure is schematically illustrated in six steps (Figure 7).\u003c/p\u003e\n\u003cp\u003eThe patient was successfully weaned from cardiopulmonary bypass and transferred to the intensive care unit in stable condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Course and Follow-Up\u003c/strong\u003e The patient had an uneventful recovery. He was extubated within hours and weaned off inotropes by postoperative day two. Postoperative echocardiography demonstrated significant improvement in ventricular geometry, with resolution of the dyskinetic segments and improved systolic function.\u003c/p\u003e\n\u003cp\u003eThe patient was discharged on optimal medical therapy including dual antiplatelet therapy, beta-blockers, ACE inhibitors, and diuretics. At four-year follow-up, he remains asymptomatic, in NYHA Class I, with preserved LV systolic function and no evidence of recurrent aneurysm or thrombus on serial imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e Although SVR was once widely performed, its use has declined significantly in the current era due to earlier detection of myocardial infarction and the widespread availability of percutaneous coronary intervention (PCI) and optimized medical therapy [2]. As a result, fewer patients progress to the chronic remodeling phase that previously made them surgical candidates. Nevertheless, SVR remains a valuable option in specific cases, particularly those involving large dyskinetic aneurysms or suspected left ventricular rupture, where medical therapy alone may not suffice.\u003c/p\u003e\n\u003cp\u003eThe Dor procedure, first described in 1985, involves aneurysm resection, thrombus removal, and endoventricular patch plasty to exclude the scarred myocardium and restore left ventricular geometry [3]. This technique has been shown to improve symptoms, reduce LV volume, and in some series, improve long-term survival [4].\u003c/p\u003e\n\u003cp\u003eIn this report, we present the case of a 55-year-old male with a history of untreated myocardial infarction who developed a large anterior LV aneurysm with suspected contained rupture. The patient underwent urgent surgical intervention using the Dor procedure, resulting in a successful recovery and excellent long-term outcome. This case highlights the relevance of SVR in contemporary practice and offers insight into the management of complex ischemic ventricular remodeling.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough surgical ventricular restoration (SVR), particularly the Dor procedure, is no longer routine in the era of percutaneous coronary intervention (PCI), it remains a critical option in select cases of severe ischemic left ventricular (LV) remodeling, especially when complicated by aneurysm or suspected rupture [1,2]. This case highlights how the Dor procedure can offer a life-saving solution in a hemodynamically vulnerable patient with extensive anterior wall dysfunction.\u003c/p\u003e\n\u003cp\u003eSVR aims to restore ventricular geometry, reduce wall stress, and eliminate non-functional myocardium, thereby improving overall cardiac function [3,4]. Our patient presented with imaging findings highly suspicious for contained LV rupture—a condition associated with significant mortality if left untreated. Prompt identification and timely surgical intervention allowed for successful aneurysm exclusion and restoration of ventricular architecture, with preservation of long-term function.\u003c/p\u003e\n\u003cp\u003eWhile the STICH trial (Surgical Treatment for Ischemic Heart Failure) reported no overall survival benefit from adding SVR to CABG in a broad cohort, subgroup analyses suggest benefit in highly selected patients—particularly those with discrete aneurysmal segments and preserved basal contractility [5]. Further, the STICHES extension trial showed that long-term survival with CABG is improved over medical therapy alone, supporting aggressive surgical approaches in ischemic cardiomyopathy [6]. In this context, our patient, with a localized, severely dyskinetic aneurysm and suspected rupture, fits the profile of those most likely to benefit from SVR.\u003c/p\u003e\n\u003cp\u003eTechnical success in SVR depends on several key steps: accurate preoperative imaging, complete thrombus evacuation, careful delineation of viable myocardium, and precise patch tailoring to optimize LV geometry. In our case, the combination of transthoracic echocardiography, ECG-gated CT, and intraoperative transesophageal echocardiography (TOE) enabled comprehensive assessment of the aneurysm. The use of an intra-aortic balloon pump (IABP) preoperatively provided hemodynamic support and likely contributed to the stable postoperative course.\u003c/p\u003e\n\u003cp\u003eAlthough SVR is rarely performed today, long-term studies from Dor and others have demonstrated durable outcomes in terms of functional improvement and survival, particularly when the procedure is performed in experienced centers and appropriately selected patients [1,3,7]. This case reinforces that message: even in the modern PCI era, surgical solutions have an important place in complex ischemic heart disease.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights that surgical ventricular restoration using the Dor procedure remains a highly effective, though underutilized, intervention for selected patients with ischemic left ventricular aneurysms\u0026mdash;particularly when complicated by suspected rupture. In the setting of localized, non-contractile myocardium and hemodynamic compromise, timely surgical intervention can restore ventricular geometry, prevent catastrophic progression, and significantly improve long-term functional outcomes.\u003c/p\u003e \u003cp\u003eDespite the modern dominance of percutaneous interventions and optimized medical therapy, this case reaffirms the enduring relevance of surgical techniques such as the Dor procedure. When performed with meticulous planning and patient selection, SVR can provide durable survival and symptomatic relief, even years after myocardial infarction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent was obtained from the patient for the publication of this case report and all accompanying images. All images included in the manuscript are original and were obtained during the clinical management of the patient. The signed consent form is available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors received no specific funding for this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDor V, Sabatier M, Montiglio F, Civaia F, Di Donato M. Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience. Semin Thorac Cardiovasc Surg. 2001;13(4):435\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eAthanasuleas CL, Buckberg GD, Stanley AW, Siler W, Dor V, Di Donato M, et al. Surgical anterior ventricular endocardial restoration (SAVER) in the treatment of dilated ischemic cardiomyopathy. J Am Coll Cardiol. 2004;44(5):973\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMenicanti L, Castelvecchio S, Ranucci M, Frigiola A, Santambrogio C, De Vita C, et al. The Dor procedure in ischemic cardiomyopathy: long-term results of the surgical treatment of ischemic heart failure study. Ann Thorac Surg. 2007;84(6):2052\u0026ndash;60.\u003c/li\u003e\n \u003cli\u003eJatene AD. Left ventricular geometric reconstruction in the treatment of heart failure. Arq Bras Cardiol. 2002;78(2):193\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eJones RH, Velazquez EJ, Michler RE, Sopko G, Oh JK, O\u0026rsquo;Connor CM, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med. 2009;360(17):1705\u0026ndash;17.\u003c/li\u003e\n \u003cli\u003eVelazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374(16):1511\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eDi Donato M, Sabatier M, Dor V, Toso A, Barletta GA. Surgical ventricular restoration: left ventricular shape influence on cardiac function, clinical status, and survival. Ann Thorac Surg. 2002;74(5):1471\u0026ndash;6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dor procedure, surgical ventricular restoration, left ventricular aneurysm, myocardial infarction, ventricular rupture, cardiac surgery, endoventricular patch plasty","lastPublishedDoi":"10.21203/rs.3.rs-6505699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6505699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Surgical ventricular restoration (SVR) using the Dor procedure has become increasingly rare in the era of modern revascularization and improved medical management of myocardial infarction. However, in selected patients with severe left ventricular (LV) remodeling or suspected rupture, it remains a critical surgical option.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e A 55-year-old male presented with acute chest pain and dyspnea. Imaging revealed an extensive anterior LV aneurysm with suspected contained rupture. After successful LAD revascularization, the patient underwent SVR using the Dor procedure. Intraoperative findings confirmed a large thrombus and dyskinetic segments, which were excluded using a Dacron patch. Postoperative recovery was uneventful.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome:\u003c/strong\u003e At four-year follow-up, the patient remains asymptomatic with preserved LV function and no signs of recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This case illustrates that the Dor procedure remains a valuable life-saving strategy in select patients with post-infarction LV aneurysms and suspected rupture, particularly when rapid diagnosis and timely surgical intervention are achieved.\u003c/p\u003e","manuscriptTitle":"Surgical Ventricular Restoration with the Dor Procedure for Anterior LV Aneurysm and Suspected Rupture: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 07:12:28","doi":"10.21203/rs.3.rs-6505699/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f1b5f5d-c1bd-456d-80e3-c1b787615024","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-06T06:54:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 07:12:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6505699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6505699","identity":"rs-6505699","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}