left ventricular aneurysm
DESCRIPTION
Definition of LVA Centerline analysis of RWMA on LV angio in 30º RAO shows hypocontractile segments moving more than 2 standard deviations out of normal range.TRANSCRIPT
![Page 1: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/1.jpg)
Dr R.C Barik/Dr A N PatnaikNIMS, Hyderabad
LEFT VENTRICULAR ANEURYSM REPAIR
![Page 2: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/2.jpg)
TIMELINE FACTS COMMENTS
1757
1881
1912
1944
1951
1955
1958
LV ANEURYSM by autopsy
LVA+ CAD
Congenital LVA Rx-surgical ligation
Fasciae latae plication.
First LV ANGIOGRAM
LVA repair without CPB
Cooley et al successfully performed a linear repair of a LVA using CPB.
Geometric ventricular techniques
John Hunter
Weitland
Beck
Likoff and Bailey
Stoney et al, Daggett et al,
Dor et al, Jatene, and Cooley et al.
![Page 3: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/3.jpg)
NATURAL HISTORY OF CAD
In MI with LV-Aneurysm-20% survivors develop symptomatic HF in 5 years and 50% die in 1 st 1-2 yr even with advance HF Rx.(NHLBI)
Aim 1.The intervention timing-symptom/aneurysm size/CAD
2.Define the aneurysm-ECHO/LV ANGIOGRAM/CMRI.3.Surgical ventricular reduction
![Page 4: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/4.jpg)
MR.X
age: 78 year / M
DM II,HTN,CKD-10 yrs
CAD S/P PTCA PROX RCA AND DISTAL LAD - 7 yrs
back.
PAD-RT great toe amputation-7 yr back .
Old CVA-lacunar infarct improved-7 yr back .
STEMI (AWMI)-S/P-STK+, PTCA- PROX LAD / DISTAL
RCA-and discharged -10/2012
PATIENT PROFILE
![Page 5: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/5.jpg)
CAG-11/10-2012
![Page 6: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/6.jpg)
PRIMARY PTCA TO PROX LAD -10/2012
![Page 7: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/7.jpg)
CAG-10/2012
![Page 8: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/8.jpg)
RCA STENTING-10/2012
![Page 9: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/9.jpg)
Readmitted with gross Heart Failure,
NYHA-IV
2 syncopal attacks .
NO ANGINA
LV-apical aneurysm with clot
10/12/2012
![Page 10: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/10.jpg)
ON EXAMNINATION
BMI-24KG/M²
Raised JVP and B/L mild pedal edema
PR-86/min ,BP- 130/90 mmHg.
Dyskinetic apex, no murmur
PVD+(amputed- right great toe ).
No neurological deficit
Other systems normal.
![Page 11: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/11.jpg)
PREOP EVALUATION
![Page 12: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/12.jpg)
PROFILE OBSERVATION
ROUTINE LAB HB,-9.2GM%,FBS-154,Urea-24,Cr-1.7GM%,RBS-227.normal
electrolytes
ECG Q wave in V1-V5,ST-Elevation in V2,3,4
X-Ray Chest- Cardiomegaly-protruded left heart border .
2D ECHO- RWMA-in LAD territory , Large Apical Aneurysm ,Severe LV-
Dysfunction ,EF- 30 %, Gr-1 Diastolic Dysfunction .no MR/VSD.
INVESTIGATION
![Page 13: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/13.jpg)
PRE OP ECG-EXTENSIVE AWMI
![Page 14: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/14.jpg)
LV ANEURYSM
![Page 15: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/15.jpg)
CORONARY ANGIOGRAM-( F-4122 / 11-12-2012) LAD- Proximal & Mid Stent Patent ,Total occlusion in distal LAD after
the 2nd STENT
LCX- Non dominent . Near total occlusion
OM1- Diffusly Disseased .
RCA- Dominant , both Stent patent in Proximal and distal RCA
PDA- Diffusly Disseased.
LV-Angio- Mod LV-Dysfunction , Large apical aneurysm +.
B/L-Renal artery – 30% Stenosis in Both Renal arteries .
B/L LL Arteries- Diffusly disseased with multiple stenosis in
femoral artery .
![Page 16: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/16.jpg)
LCX-SUBTOTAL AND GOOD SIZE OM1-11/12/2012
![Page 17: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/17.jpg)
LAD-2 DES AND DISTAL ISR 100% 12/2012
![Page 18: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/18.jpg)
RCA-PROX AND DISTAL DES PATENT-12/2012
![Page 19: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/19.jpg)
LV ANGIO IN RAO 30º-12/2012
ANEURYSM OF EVENING
![Page 20: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/20.jpg)
CARDIAC MRI-20/12/2012
LV
EDD=5.5/ ESD=4.1CM
EDV: 127ml/m2, ESV: 84ml /M2(CRITICAL VOL-
120/80ML/M²)
EF: 33% SV: 43ml
CO: 3.1L/m2,
LV Mass: 149gm /m2
![Page 21: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/21.jpg)
TERRITORY BASELINE PEAK STRESS
Basal LVAnterior/Post-septum
Anterior/Post/ALW/PL Wall
MID LV: Anterior/Post septum
Anterior/PW AW/PW
APICAL LV: Anterior Posterior
Septal Lateral Apex:
1 in all segments
2/12/11/1
4444
LEFT VENTRICULAR WALL MOTON ANALYSIS
![Page 22: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/22.jpg)
LV Apical aneurysm 2C area :S=18sqcm, D=15sqcm 4C area S=14sqcm, D=13sqcm Neck>3cm
Delayed Enhancement: No myocardial edema. Basal LV : 0 - 25% subendocardial DCE Mid LV: 25-50% subendocardial DCE in AW
and ant septum.Distal LV and APEX:transmural DCE
![Page 23: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/23.jpg)
: CMRI CONCLUSION
Type III LVA.RWMA in LAD territory Severe LV dysfunction 0-25% subendocardial scar in proximal LAD territory
(viable) 25-50% subendocardial scar in mid LAD territory (partially
viable) Transmural scar in distal LAD territory (non viable) LV Apical aneurysm Significant hibernating myocardium in LAD territory RV : Normal size & function Mild MR/No LV thrombus/No pericardial effusion
![Page 24: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/24.jpg)
ANEURYSM REPAIR+CABG
To be worthy of operation, A dyskinetic or akinetic left ventricular aneurysm should significantly enlarge left ventricular end-systolic volume index (over 80 mL/m2) and end-diastolic volume (over 120 mL/m2)-CRITICAL VOLUME and surgery aims at minimum on table LV volume by mannicune 50 ML/M² Relative indication 1.CHF/arrythmia/embolism/rupture
Aim: correct the size and geometry of the LV, reduce wall tension
and improve pump function, functional status and survival.
![Page 25: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/25.jpg)
CABG X1 graft-SVG to LAD.
Huge Cardiomegaly. Moderate pericardial effusion.
Apex and lateral wall adherent to pericardium.
Large LV apical aneurysm extending to lateral wall, wall thinned
out and fibrosed. Small fresh clot in aneurysm wall.
Papillary muscles, separated widely, few chordae elongated.
LAD- Extending into aneurysm wall, plaques+. LAD involving
stented area thickened.
INTRA OPERATIVE FINDINGS (ON PUMP+CBP)-DATED-----26/12/2012 and
discharged 7/01/2013
![Page 26: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/26.jpg)
True ischemic dilated cardiomyopathy (Type 3)
![Page 27: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/27.jpg)
![Page 28: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/28.jpg)
![Page 29: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/29.jpg)
The mannequin is inflated at 50 ml/m2 and inserted into the ventricle.
![Page 30: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/30.jpg)
Dacron patch
![Page 31: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/31.jpg)
![Page 32: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/32.jpg)
Fontan’s stich
![Page 33: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/33.jpg)
![Page 34: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/34.jpg)
The patch (Dacron) is tailored if neck>3cm
![Page 35: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/35.jpg)
![Page 36: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/36.jpg)
![Page 37: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/37.jpg)
![Page 38: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/38.jpg)
POST OP ECG-JUST EVOLVED ASWMI
![Page 39: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/39.jpg)
Post OP X-RAY ON 7/2/2013
![Page 40: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/40.jpg)
Post OP ECHO
EDV-110ML/M²ESV-60ML/M²
LVEF>45%
07-02-2013
![Page 41: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/41.jpg)
Post Operative fol low up
Now under admission for
Pedal edema due to stasis-SVG to LAD
No CHF
Ef-40%-50%
Sutural line infection(sternal)-now under Rx.
Acute on chronic renal failure-now under Rx
![Page 42: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/42.jpg)
Definit ion of LVA Centerl ine analysis of RWMA on LV angio in 30º RAO shows hypocontracti le segments moving more than 2 standard deviat ions out of normal range.
DISCUSSION
![Page 43: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/43.jpg)
Causes of LVA
Preserved contractility of surrounding myocardium
Transmural infarction
Lack of collateral circulation
Lack of reperfusion
Elevated wall stress
Hypertension
Ventricular dilation
Wall thinning
![Page 44: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/44.jpg)
Coronary Artery Surgery Study (CASS)-
7.6% had angiographic evidence of left ventricular
aneurysms.
95% of true LV aneurysms after MI
False aneurysms of the LV from contained rupture 5 to 10
days after MI and mostly in LCX lesion
LVA occurs within 48 hours-50% and
2 weeks-100% after infarction.
88% of dyskinetic ventricular aneurysms after AWMI.
![Page 45: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/45.jpg)
Linear repair and septoplasties by Cooley .
![Page 46: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/46.jpg)
Repair of anteroseptal ventricular aneurysm by Stoney
![Page 47: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/47.jpg)
capitonnage technique by Cabrol
![Page 48: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/48.jpg)
Overcoat Aneurysmoplasty By Guilmet
![Page 49: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/49.jpg)
LV reconstruction with a Dacron patch by Levinsky
![Page 50: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/50.jpg)
LV reconstruction technique by Jatene.
![Page 51: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/51.jpg)
The endoventricular circular patch plasty (Dor procedure)
![Page 52: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/52.jpg)
Dor’s procedureIn the endoventricular circular patch plasty by Dor, the
procedure is carried out under cardioplegia.
The left ventriculotomy is performed in the akinetic or dyskinetic zone (transaneurysmal ventriculotomy), the thrombus is removed .
An endoventricular circular suture (Fontan maneuver) is placed 1 cm distal to the border of healthy muscle in order to prevent its inclusion and allows recreation of the normal shape of LV using continuous 2-0 monofilament polypropylene suture.
![Page 53: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/53.jpg)
Dor’s procedure
Following this, a balloonis placed in LV cavity and inflated to the theoretical diastolic volume of 50—70 ml/m2, and the circular suture is tightened and tied up.
This maneuver makes the definition of the circular patch size easier, which can consist of autologous (endocardium or pericardium) or synthetic tissue.
The patch size is trimmed to match the circular suture circumference after deflation of the balloon.
The patch is fixed by a continuous 2-0 suture inside the LV cavity on the border labeled by the circular suture.
![Page 54: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/54.jpg)
Post Operative ComplicationsLow cardiac output - 22%–39%Ventricular arrhythmias - 9%–19%Respiratory failure - 4%–11%Bleeding - 4%–7%Dialysis-dependent renal failure - 4%Stroke - 3%–4%
![Page 55: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/55.jpg)
SVR (Surgical ventricular restoration).Reduces LV volumesRestore ell iptical shape Remodell ing (LAPLACE’S LAW).INCREASE EFREDUCES WALL STRESS AND LVEDP.INCREASE STROKE WORK
Based on the following observation
![Page 56: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/56.jpg)
10 YR survival is 90% in asymptomatic and 46% in symptomatic
Survival in medically treated patients with left ventricular aneurysm based on presence (group B) or absence (group A) of symptoms. (Grondin P, et al: Natural history of saccular aneurysm of the left ventricle. J Thorac Cardiovasc Surg 1979; 77:57.)
![Page 57: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/57.jpg)
The diagram shows the strict relationship between spericity index (short/long axis) on the abscissa and ejection fraction (ordinate).
Menicanti L , Di Donato M MMCTS 2005;2005:mmcts.2004.000596
© 2005 European Association for Cardio-thoracic Surgery
![Page 58: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/58.jpg)
Effects of aneurysmectomy on VEDV), ejection fraction (EF), and wall tension. Hemodynamic assessment during exercise after left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1994; 107:178.)
![Page 59: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/59.jpg)
Relationship between stroke work index and left ventricular end-diastolic pressure. Hemodynamic assessment during exercise after left ventricular aneurysmectomy. J Thorac Cardiovasc Surg 1994; 107:178.)
![Page 60: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/60.jpg)
Simulated left ventricular aneurysm and aneurysm repair in swine. J Thorac Cardiovasc Surg 1990; 100:745.
![Page 61: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/61.jpg)
Survival in patients with left ventricular aneurysm and three-vessel coronary disease treated with medical or surgical therapy . The inf luence of surgery on the natural history of angiographically documented left ventricular aneurysm: the Coronary Artery Surgery Study. Circulat ion 1986; 74:110.)
![Page 62: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/62.jpg)
Repair of dyskinetic or akinetic left ventricular aneurysm: results obtained with a modif ied l inear closure. J Thorac Cardiovasc Surg 2001; 121:675.
![Page 63: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/63.jpg)
Summary of the results obtained with SVR NON RANDOMISED AND NON COMPARATIVVE
Menicanti L , Di Donato M MMCTS 2005;2005:mmcts.2004.000596
© 2005 European Association for Cardio-thoracic Surgery
BEFORE STICH TRIAL
EHA
![Page 64: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/64.jpg)
.
RESULTS OF STICH trial (Surgical Treatment for Ischemic Heart Failure)are recently published
![Page 65: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/65.jpg)
Surgical Treatment for Ischemic Heart Failure (STICH) tr ial( -VE
TRIAL)
![Page 66: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/66.jpg)
But we are hopeful larger study only clarify Because 1.NEW TECH 2.DEVICES 3.CPB AND ANAES.
ANATOMICAL LV VOLUME REDUCTION HAS NO EFFECT ON KAPLAN-MAYER’S LIFE SURVIVALPROJECTION OVER 5 YRS
![Page 67: Left ventricular aneurysm](https://reader034.vdocuments.mx/reader034/viewer/2022052601/55942fa01a28ab4c3d8b46bb/html5/thumbnails/67.jpg)
TAKE HOME MESSAGEIN ABSENCE OF PRECISE GUIDELINES TO
MANAGE LV-ANEURYSM FOLLOWING AMI ,INDIVIDUALISED SURGICAL APPROACH AFTER CAREFUL CLINICAL AND IMAGING ASSESMENT CAN GIVE GRATIFYING RESULT AS IN THIS CASE .
Thank you