Survival and Cardiac Performance After Left Ventricular Aneurysmectomy

Abstract

Reconstruction of the left ventricle was performed in 24 consecutive male patients with symptomatic, paradoxically expanding post-infarction ventricular aneurysms during the 13-year-period ending 1973. One patient also required prosthetic mitral valve replacement because of papillary muscle dysfunction and another patient patch closure of a post-infarction septal perforation. Four other patients underwent coronary artery bypass grafting in addition to the aneurysmectomy. All patients except 3 were seriously limited functionally, corresponding to capacity groups III and IV (N.Y.H.A.), and congestive heart failure refractory to medical therapy dominated the clinical status in most patients. A rather pronounced cardiomegaly, low physical working capacity, hypokinetic central circulation with small effective stroke volume and low cardiac output, elevated filling pressure and moderate pulmonary hypertension reflected serious impairment of LV-pump function.

Hospital mortality was 21% (5/24 patients) and closely related to the condition of the residual myocardium. There was no early mortality among patients undergoing combined procedures. All long-term survivors improved by at least one functional capacity group. The major late haemodynamic effects of aneurysmectomy were an increase in effective stroke volume and a decrease in LV-filling pressure at rest and during exercise, accompanied by a reduction or normalization of pulmonary hypertension, whereas the circulation usually remained hypokinetic. After surgery, the heart had regained much of its ability to increase stroke work during exercise, although cardiac performance was not restored to normal in the majority of patients. None of the patients suffered from thrombo-embolism postoperatively. The 5-year actuarial survival of 50% indicates a definite improvement over the natural history of left ventricular aneurysm.

It is evident from our experience and from the reports of others that surgery has a well-established position in the treatment of post-infarction LV-aneurysms with paradoxical expansion. Aneurysmectomy offers beneficial symptomatic and haemodynamic improvement and increases the chance of survival. The size of the residual LV-chamber, its blood supply and performance are important factors in the selection of candidates for surgery.