Surgical restoration of the left ventricle for postinfarction aneurysm

Background. Surgical left ventricular reduction is under investigation as an alternative to, or a bridge for, heart transplantation in patients with a left ventricular aneurysm. In fact, acute myocardial infarction can result in the development of a dyskinetic or akinetic left ventricular aneurysm which may in turn cause congestive heart failure, ventricular arrhythmias, and the formation of mural thrombi. The aim of this study was to evaluate the current operative risk of surgical restoration of the left ventricle and the early and late clinical results. Methods. From January 1997 to December 2001, 94 patients (84 males and 10 females) presenting with a postinfarction aneurysm were submitted to surgical restoration of the left ventricle. All patients presented with symptoms of heart failure and/or angina. The preoperative NYHA functional class was: I in 6 patients, II in 22 patients, and III in 66 patients. No patient was in NYHA class IV at the time of surgery. The preoperative ejection fraction was 30 ± 7.9%. In 25 patients mural thrombi were identified and surgically removed. In patients with preoperative evidence of ventricular arrhythmias the Harken procedure was performed intraoperatively. The ventricular preoperative and postoperative performances were also studied in 10 patients using P-V loops obtained through a conductance catheter. Results. The in-hospital mortality was 3.2%. The mean length of hospitalization was 7 ± 2.9 days. At follow-up (mean 26 ± 14.8 months) we observed an early improvement in the ejection fraction (30 ± 7.9 vs 48 ± 8.0%) and a decrease in the end-diastolic and end-systolic volumes and mean pulmonary pressure (139 ± 37 vs 84 ± 17 ml/m², 105 ± 39 vs 52 ± 20 ml/m², 35 ± 8.4 vs 23 ± 4.3 mmHg). Conclusions. These results suggest that ventricular restoration is indicated in all patients with a postinfarction dyskinetic or akinetic aneurysm. The operation, if performed appropriately, is associated with a low in-hospital mortality and morbidity. A postoperative improvement in the early and long-term cardiac functions was demonstrated. An improvement in symptoms and quality of life was documented, increasing our expectations of an increased long-term survival.