Thorax (1964), 19, 162

Ventricular AneurysmVIKING OLOV BJORK

From the Department of Thoracic Surgery, University Hospital, Uppsala, Sweden

A cardiac aneurysm represents a diseased andweakened cardiac wall, which will balloon outduring systole. Approximately 85% of suchaneurysms are caused by coronary occlusion.Cardiac aneurysms usually involve the leftventricle; those of the right ventricle are rare.Most of these aneurysms develop during theperiod of myocardial necrosis and softening,especially during the first few weeks after coronaryocclusion. Experimental evidence supports thebelief that the development of a ventricularaneurysm is favoured by allowing a patient to beup and walking around too soon, which meanswithin a week or two after an acute infarction. Aventricular aneurysm may follow necrosis of themyocardium caused by rheumatic fever and mayalso be caused by infective endocarditis withabscess of the myocardium, particularly in associa-tion with mycotic coronary arteritis, congenitaldefects, and trauma. Spontaneous rupture of acardiac aneurysm is rare. If it does occur, it ismost likely to occur during the first 10 days afterthe onset of an infarction. The usual terminal eventis cardiac failure or embolization.John Hunter (1757) first described a ventricular

aneurysm. Schlichter, Hellerstein, and Katz (1954)stated that the prognosis was half as favourablein a patient developing an aneurysm after myo-cardial infarction as in others. In a series ofpatients with cardiac aneurysm, 73% died withinthree years and 88% died within five years. Thecause of death in 70% was congestive heart failure.The presence of a non-contractile sac on theanterior surface of the left ventricle impairs thenormal contractile force of the left ventricle andthus significantly reduces cardiac output.The first attempt to operate on a left ventricular

aneurysm was made by Beck (1944). GordonMurray reported three years later upon the experi-mental excision of myocardial infarcts andshowed that the cardiac output could be increasedby removing the expansion chamber. Bailey,Bolton, Nichols, and Gilman (1958) reported theexcision of ventricular aneurysms using a specialclamp at a closed operation. Cooley, Collins,

Morris, and Chapman (1958) reported the firstsuccessful open operation for a massive left ven-tricular aneurysm; they used a pump oxygenatorfor temporary cardiopulmonary by-pass.The purpose of this paper is to report seven

cases of ventricular aneurysm treated at theThoracic Surgical Clinic of the University ofUppsala; five were acquired left ventricularaneurysm, one was a congenital left ventricularaneurysm, and one was a right ventricularaneurysm.

MATERIAL

The cases are summarized in the Table. There wasone small left ventricular aneurysm combined witha mitral stenosis, and one large right ventricularaneurysm combined with a large 5 x 4 cm.secundum atrial septal defect and a 20-litres shuntfrom the left to the right atrium in a huge heartof 910 ml./m.2 body surface area and a rightventricular pressure of 45 mm. Hg.Four aneurysms had developed following infarc-

tion. In two the aneurysm included the apex of theleft ventricle with significant paradoxical move-ments (case 3 (Fig. 1) and case 4 (Fig. 2) ). In case5 the aneurysm included a 5 x 5 cm. large fibroticarea on the anterior part of the left ventricle withno movements. The patient had undergone acoronary thrombendarterectomy of the leftdescending artery without obtaining a good retro-grade flow and without improvement and was infailure. The oldest patient (case 6) was 60 years ofage; he had a similar high anterior left ventricularaneurysm but with calcification in the wall pre-venting movements. There were scattered, large,white scars in the myocardium (Fig. 3).Case 7 had a congenital aneurysm of the left

ventricular apex, separated by a fibrotic membranefrom the left ventricular chamber. The communi-cation was so small that the contrast medium usedto fill the left ventricle did not pass into theaneurysm, although the cavity was as big as anorange, nor could an opening from the aneurysminto the ventricle be found at open operation,

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Ventricular Aneurysm

TABLEFINDINGS IN SEVEN PATIENTS WITH LEFT VENTRICULAR ANEURYSM

Size of Aortic Respi-Heart Aneu- Perfu- Occlu- rator Obser-

Diagnosis Size rysm sion sion Treat- vationAge Sex Diagnosis Confirmed by (ml. m.2) (cm.) Surgery (min.) (min.) ment (yr.) Results

48 F Mitral stenosis Operation 840 2 x 2 Commissuro- 0 0 0 5 Alive and well+ left ventricular tomy + obli-aneurysm teration by

mattresssutures overpericardialstrips

39 F Atrial septal Operation 910 4 x 4 Closure of 0 + 2 Alive and welldefect + right A.S.D. + Heart nowventricular patch rein- 590 ml. 'm. 2aneurysm forcement of

aneurysm +pacemakerHypothermia

58 M Post-infarction Angiocardio- 620 5 x 5 Excision 52 31 + 2 Recurrence;left ventricular graphy from died afteraneurysm pulmonary reoperetion

artery52 M Post-infarction Operation 650 5 x 5 Excision 53 16 + 3 Alive and well

left ventricularaneurysm

52 M Post-infarction Angiocardio- 490 5 x 5 Excision 57 + + I Aliveleft ventricular graphy fromaneurysm pulmonary

artery60 M Post-infarction Angiocardio- 600 5 x 5 Excision 61 3 + 0 Died 5 days

calcified left graphy from after operationventricular left atriumaneurysm (transseptal)

22 IM Congenital left Angiocardio- 490 5x6 Excision 65 21 + 2 Alive and wellventricular graphyaneurysm

although the aneurysm was filled with blood with-out thrombosis.

DIAGNOSIS

The diagnosis was unexpected and made atoperation in the patient who had aneurysm com-

FIG. 1

FIG. 1. Case 3. A huge apical left ventricular aneurysmwith paradoxical movement in a 58-year-old man.FIG. 2. Case 4. A huge left ventricular apical aneurysmwith significant paradoxical systolic expansions in a52-year-old man.

bined with mitral stenosis and in the patient withatrial septal defect as well as in one patient whounderwent surgery for angina pectoris. In fourpatients the diagnosis was made before operationand confirmed by pulmonary artery angiography;paradoxical or no left ventricular wall movement

FIG. 2

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Viking Olov Bjirk

FIG. 3. Case 6. The wall of the anterior left ventricularaneurysm shows cakification, and numerous large whitescars can be seen scattered around the left ventricle andon its posterior surface in a 60-year-old man.

i,,9~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.s.'FIG. 4. Case 2. A huge thin-walled anterior rightventricular localized aneurysm in a 39-year-old womanwith a heart of910 ml./m.2 was treatedby apatch reinforce-ment with mattress sutureS over strips of teflon. Theparadoxical movements were controlled by this patchreinforcement. Wires were applied to the myocardiumfor an external pacemaker as a total block developed.Closure of the secundum defect was performed by con-

tinuous and isolated mattress sutures under inflow occlusionduring hypothermia at 300 C. After a year the heart sizehas diminished to 590 ml/m.2; spontaneous rhythm isbetween 50 and 60 beats per minute, increasing to 80-90during a work load test. The pacemaker is still used as

it is hoped the block will disappear when the heart size isdiminished.

was observed as well as no trabeculation on theinside of the left ventricular wall when theaneurysm was filled with thrombotic material.

SURGICAL TECHNIQUE

The smallest aneurysm was treated by mattresssutures over strips of pericardium which controlledthe paradoxical movements.The right ventricular aneurysm was treated by

a patch reinforcement as the thin dilated adjacentright ventricular wall would not hold sutures safelyafter an excision. The paradoxical movementswere controlled by this patch reinforcement (seeFig. 4).The large acquired and congenital left ventricu-

lar aneurysms were excised at open operationusing a heart-lung machine to prevent embolismand improve the haemodynamics. A bilateral sub-costal incision entering the left fifth and the rightfourth intercostal spaces with transverse section ofthe sternum was used. The perfusion time wasabout one hour, and the aorta was occluded foronly a short time at the beginning of perfusion,when the aneurysm was opened, to preventembolism.

After the aneurysm had been opened, all thethrombotic material was evacuated, then theaneurysm was excised, care being taken not totake so much of the left ventricular wall as tomake the left ventricle too small. The papillarymuscles were inspected and avoided. It was foundadvisable to leave the last centimetre of fibrotictissue at the periphery of the aneurysm as thistissue seemed to hold sutures better than the myo-cardium itself (see Fig. 5). Mattress and over-and-over isolated sutures were applied over stripsof teflon to reinforce the suture lines. (See Fig. 6.)As the ventriculotomy was closed the left

ventricle was allowed to fill with blood, and therewas no problem with air embolism in these cases.The pericardium was closed over the suture linebut left open at the base of the heart. Six patientsneeded post-operative respirator treatment.

RESULTS

The results are summarized in the Table. One 60-year-old patient (case 6) died five days afteroperation. He had a calcified wall of the aneurysmwhich prevented paradoxical movements. Weconsidered that this large patch of calcium, whichmade most of the anterior part of the left ventricleimmobile, impaired the ventricular work enough towarrant excision. Experience from case 5, where ahuge fibrotic immobile left anterior ventricular

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Ventricular Aneurysm

FIG. 5 FIG. 6

FIG. 5. Case 3. The aneurysm is excised, leaving a 1 cm. rim of fibrotic tissue. FIG. 6. Case 3. Closure iseffected by one row of mattress sutures and one row ofover-and-over sutures applied over strips of teflon.

wall had been excised, led us to anticipate someimprovement in a severely ill patient in failure.In case 6, however, the remaining part of the leftventricle was also severely changed by scattered,numerous, white, fibrotic scars. Too little improve-ment could therefore be gained from the operation,and death occurred.One 58-year-old man was much improved for

one and a half years. Then during anticoagulationtreatment a false aneurysm with communication tothe left ventricle through the suture line occurred.He died after reoperation.The best results were obtained in patients with

aneurysm having paradoxical movements. Carefulstudy by angiocardiography from the left atrium(transseptally) or from the pulmonary artery inorder to determine the degree of systolic expansionof the aneurysm and the contractility of theremaining part of the left ventricle is essentialbefore excision is contemplated.

In conclusion four patients were significantlyimproved, one was not improved, and two died.

DISCUSSION

In patients with ventricular aneurysm the strokevolume of the left ventricle at rest is reducedbecause the force of contraction of the remainingmyocardium is dissipated in the flaccid sac. This

is most evident during exercise. The good resultreported by Cooley et al. and found in our serieshas made us accept excision of ventricularaneurysm as the correct method of treatment inselected cases.

SUMIMARY

Seven cases of ventricular aneurysm are reported:one small left ventricular aneurysm was treated bymattress sutures; one right ventricular aneurysmwas reinforced by a patch; five large left ventricu-lar aneurysms, one of them congenital and fourfollowing infarction, were excised at open opera-tion using the heart-lung machine. Two patients inthis group died and four were improved.

REFERENCES

Bailey, C. P., Bolton, H. E., Nichols, H., and Gilman, R. A. (1958).Ventriculoplasty for cardiac aneurysm. J. thorac. Surg., 35, 37.

Beck, C. S. (1944). Operation for aneurysm of the heart. Ann. Surg.,120, 34.

Cooley, D. A., Collins, H. A., Morris, G. C., and Chapman, D. W.(1958). Ventricular aneurysm after myocardial infarction.Surgical excision with use of temporary cardiopulmonary bypass.J. Amer. med. Ass., 167, 557.

-Henly, W. S., Amad, K. H., and Chapman, D. W. (1959).Ventricular aneurysm following myocardial infarction: Resultsof surgical treatment. Ann. Surg., ISJ, 595.

Hunter, J. (1757). An account of the dissection of morbid bodies.Original manuscript in the library of the Royal College ofSurgeons. No. 32, p. 30.

Murray, G. (1947) The pathophysiology of the cause of death fromcoronary thrombosis. Ann. Surg., 123, 523.

Schlichter, J., Hellerstein, H. K., and Katz, L. N. (1954). Aneurysmof the heart: a correlative study of 102 proved cases. Medic ine,Baltimore, 33, 43.

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