Thorax (1969), 24, 148. Cardiac ventricular aneurysm HUGH R. S. HARLEY From Sully Hospital, Peniarth, Glam. A case of successful excision of a ventricular aneurysm due to myocardial infarction is presented. The aetiology, incidence, pathogenesis, pathology, clinical features, and diagnosis of the condition are discussed. An account is given of the haemodynamic upset caused by aneurysms of the ventricle. The prognosis of untreated aneurysms is discussed. Although there is difference of opinion, itisconcluded thata ventricular aneurysmadverselyaffects theprognosis aftermyocardial infarction. The indications for, and the mortality and results of, resection of ventricular aneurysms are discussed. The conclusion is drawn that persistent cardiac failure and angina can be relieved and the risk of systemic embolism reduced by the excision of expansile ventricular aneurysms of a fibrous nature. It is possible that excision may also reduce the incidence of subsequent acute myocardial infarction. Ventricular aneurysm was first described in 1757 CASE HISTORY both by Hunter and by Dominicus Gusmanus Galeati. Sternberg (1914) made the first diagnosis H.C.D., a 40-year-old furniture manufacturer, was during life. He is often quoted as being the first seized by acute retrosternal pain and sweating at writer to recognize the condition of a chronic 8 a.m. on 6 October 1966. He was seen by his doctor, who gave him morphine. He was admitted aneurysm, but Cruveilhier (1827) and Rokitansky to the Medical Unit, Cardiff Royal Infirmary, on (1842-1844) had both previously attributed chronic 7 October. On examination a loud pericardial friction aneurysm to myocardial fibrosis. Sternberg (1914) sound was heard all over the precordium, most pro- forecast the possibility of radiological diagnosis minent at the left sternal edge, but there was no and this was first achieved by Sezary and Alibert evidence of either cardiogenic shock or left ventri- in 1922. cular failure. Electrocardiography showed the The first successful excision of an aneurysm features of panmural anterolateral myocardial infarc- was performed by Sauerbruch (1931) for an tion, including pathological Q waves and ST-segment aneurysm of the right ventricle of unknown elevation in leads S1, AVL, and VI to V6 (Fig. 1). aetiology found unexpectedly at the time of opera- Radiological examination showed moderate cardiac enlargement and slight elevation of the left diaphragm tion. The first planned operation for a ventricular with streaky opacities above it. but no evidence of aneurysm was described in 1944 by Beck, who left ventricular failure (Fig. 2). The serum a-hydroxy- performed external reinforcement of an aneurysm butyrate dehydrogenase level was 1,560/ml. (normal of the left ventricle with pericardium and fascia 120-260). The day after admission he developed signs lata. The first planned excision by a closed tech- of infection or infarction at the left base. He was nique using clamps was reported by Likoff and treated with ampicillin and sedatives, but anticoagu- Bailey in 1955, and the first open excision, using lants were withheld because of the pericarditis. On total cardiopulmonary bypass, was reported by 19 October 1966 he developed a right hemiplegia. Cooley, Collins, Morris, and Chapman in 1958. This recovered completely after a few days, except Since then there have been a number of reports of for occasional aphasia for numbers. On 20 October series of cases, or isolated cases, of open excision deep vein thrombosis was diagnosed in the right calf, and a radiograph of the chest showed the changes of performed in this way. The first such report from left ventricular failure (Fig. 3). Anticoagulation Britain was by Telling and Wooler in 1961. therapy was started with 100 mg. phenindione, and The case history is given here ofa patient whose continued with 50 mg. b.d., which was increased later aneurysm following myocardial infarction was to 100 mg. b.d. In addition he received two doses of excised, and the condition is discussed with special heparin (10,000 units) on the night of 21-22 October. reference to the role of surgery in its treatment. Digoxin was administered from 26 October onwards 148 Cardiac ventricular aneurysm 149 because of features of left ventricular failure. persistent ST-segment elevation and T-wave inversion Radiological examination on 3 November showed in leads Sl, AVL, and V4 to V6, and small R waves a well-marked bulge projecting from the left margin over the left precordium, but the R waves in lead of the heart in the postero-anterior view (Fig. 4), but AVR were not large (Fig. 5). The spatial vector was the changes of left ventricular failure were less. A vertical, radiographs ofthechest showed theanteriorly diagnosis of aneurysm of the left ventricle was made. placed left ventricular aneurysm in both postero- It was decided that medical management should con- anterior and lateral projections, together with tinue but that surgery should be considered in the moderate enlargement of the left ventricle and atrium future should left ventricular failure, or other debili- (Figs 6a, b, and c). The aneurysm appeared to be tating symptoms, persist or should the aneurysm about the size of a large orange, and on screening it enlarge. showed obvious systolic expansion. The rest of the During his subsequent stay in hospital radiological, ventricular wall moved normally. The results of but no clinical, features of left ventricular failure other relevant tests were as follows: S.G.O.T. 12, persisted for a while and then abated. He was dis- Hb 99%, W.B.C. 6,700/cu. cm., P.C.V. 43%. Platelet charged on 8 December 1966 on digoxin, 0-25 mg. count 135,000. Blood film normal. Urine normal. b.d., and phenindione, 100 mg. b.d. Postero-anterior Creatinine clearance 87 ml./min. Liver function tests and lateral radiographs of the chest taken on the day showed no abnormality. The lung function and before discharge showed the anteriorly placed thrombotests were satisfactory. aneurysm clearly. On 26 September 1967 the aneurysm was excised After discharge he complained of mild exertional using a bilateral anterior thoracotomy incision dyspnoea and occasionally giddy attacks, especially through the fifth intercostal spaces and the sternum. shortly after getting into bed. He had three attacks Total cardiopulmonary bypass was established for 80 of paroxysmal nocturnal dyspnoea. An attempt to minutes, the body temperature being reduced to omit digitalis was followed by a recurrence of left 30° C., and ventricular fibrillation was induced elec- ventricular failure. Because of these features it was trically before the aneurysm was excised. The left decided that the aneurysm should be excised. femoral artery and right atrium were cannulated for He was admitted to Sully Hospital under the care bypass, and the right brachial artery and the right of the writer on 16 September 1967. On examination median cubital and left saphenous veins for mano- he was a fairly fit man of 40 years. There was no metry of pressure in a proximal artery and in the clinical left ventricular failure, the blood pressure superior and inferior venae cavae. The aorta and was 137/70 mm. Hg, and no abnormal physical signs pulmonary artery were not taped because ofadhesions were found in the cardiovascular system. Electro- in the transverse sinus. The pericardium was opened cardiography showed, in addition to pathological Q by a rectangular incision, the vertical limb lying in waves in leads S1, AVL, and V4 and V5, the typical front of the right phrenic nerve and the transverse Vl ... .. It s. a; W _ 'I .v i ...~j . ................ ;,1 '.3. ,'._,... '.4 Alt'.. * -+ "I ~~~~ ..~ ~ ~~~....... AVAF V6 FIG. 1. E.C.G.taken ondayofadmissioi (7.10.66)showsfeatures ofantero-lateral myocardial infarction. 150 Hugh R. S. Harley FIG. 2. Radiograph taken on day of admission shows streaky opacities above right diaphragm but no evidence ofleft ventricularfailure. FIG. 3. Radiograph (20.10.66) shows changesofleft ventricularfailure. Cardiac ventricular aneurysm 151 limbs running to the left from the upper and lower of the left ventricle, and that the unaffected portion ends of the vertical limb. It was densely adherent of the ventricle was of good size. The aneurysm was over the region of the aneurysm. This incision enables then excised, leaving a one-centimetre rim of fibrous the pericardium to be dissected off the right atrium tissue around its periphery forthe insertion of sutures. and ventricle, and cannulation of the former to be The ventricle was closed with a layer of horizontal performed for the establishment of bypass before the mattress sutures passed through two strips of Teflon pericardium is dissected off the aneurysm. It may felt and the residual fibrous rim of the aneurysmal be advantageous to open the aneurysm before the wall, and this layer was reinforced with a continuous adherent pericardium is dissected off it in order to over and over suture which also passed through the reduce the risks of embolism and haemorrhage during Teflon strips. A few extra interrupted sutures were the dissection, and to avoid the necessity of inserting required at the upper end of the suture line. A can- a left ventricular cannula at this stage. Under the nula was brought out through the lower end of the conditions of bypass a large aneurysm was seen which incision to decompress the left ventricle. Sinus did not pulsate and which appeared to occupy most rhythm returned spontaneously during excision of the of the left ventricle. It was difficult to distinguish be- aneurysm. No haemorrhage occurred from the suture tween the aneurysmal and non-aneurysmal portions line, and when the heart beat was strong the cannula of the ventricle. The ventricles were fibrillated elec- was removed from the left ventricle. The heart came trically and an incision was then made through the off bypass easily with the support of only a single centre of the aneurysm. Its wall was composed of injection of 025 ml. adrenaline 1:80,000 given into tough fibrous tissue, with very small amounts of the right ventricle. Drainage tubes were placed in the muscle tissue near its margin, and its cavity contained pericardium and in both pleural cavities, and the considerable amounts of thrombus. The latter was chest wall closure was reinforced with two wire carefully evacuated from the aneurysm and left ven- sutures through the sternum and three pericostal tricle with a forceps and a sucker, and the left atrium sutures of catgut on each side. The exposure provided was then sucked out and carefully inspected through by the bilateral thoracotomy incisions was excellent. the mitral valve. No thrombus was found in it. The The haemodynamic recovery from the operation view of the aortic and mitral valves was exceptionally was smooth and uneventful. Forty-eight hours after good. Both valves were normal. When all thrombus operation he developed a monoplegia of the left arm. had been removed it was easy to feel the junction The arm and forearm recovered rapidly, the hand between the fibrotic wall of the aneurysm and the more slowly, especially thumb movements and wrist muscular wall of the rest of the ventricle. The wall extension. He was discharged on 2 November 1967. of the aneurysm was thinner than, and of a com- He was very well, had no congestive heart failure, pletely different consistency from, the surrounding and was in sinus rhythm, with a blood pressure of myocardium, and the junction between the two was 128/80 mm. Hg. The heart sounds were normal. well defined. After the aneurysm had been opened it Radiographs of 20 October 1967 showed the heart was obvious that it occupied the antero-lateral aspect to be definitely smaller than before the operation and FIG. 4. Radiograph (3.11.66) shows left ventricular aneurysm. Thefeatures of left ventricularfailureare lessmarked. 152 Hugh R. S. Harley the electrocardiogram of 11 October 1967 (Fig. 7) AETIOLOGY showed changes similar to those before the operation. but the segment elevation was less marked. SEX Men are affected by ventricular aneurysm Pathological examination of the resected specimen following myocardial infarction about four times showed dense collagenous fibrosis with occasional more often than women, whereas the ratio for islands of necrotic myocardium (Fig. 8). There was myocardial infarction without aneurysm is only laminated mixed thrombus of fairly recent appear- about 2 or 25 to 1. Thus Schlichter, Hellerstein, ance. and Katz (1954) found that nearly four-fifths of His subsequent progress has been excellent, and all such aneurysms occurred in men. Abrams, when last seen at the beginning of June 1968 he was Edelist, Luria, and Miller (1963) found that in very well and had no complaints, and there were no their 65 cases of ventricular aneurysm men were abnormal physical signs in the cardiovascular system. A postero-anterior radiograph showed the heart to be affected four times more often than women, much smaller than before the operation, and there whereas the sex ratio in favour of men for myo- was no evidence of left ventricular failure (Fig. 9) cardial infarction was only 1 9 to 1. Dubnow, even though he was not on digitalis. Phenindione Burchell, and Titus (1965) found that 81% of their has also been omitted. 80 patients with ventricular aneurysm following .............. V!~~~~~~~~~~~~~~~~~~~. Ii IT t _ | J *;~~~-~~46'. 0tjl Y2 V I VZ sIJ< -~~A"l AV~~~~~~~~~~~. $ t. 'I , 6~~~~~~~~~~v v AVF~ ~ ~ V6 FIG. 5. E.C.G. (18.9.67) shows the typicalpersistent S.T.-segment elevation andT-waveinversion in leads SI,AVL,and V4 to V6,and small R waves over the leftprecordium, but no enlargement ofthe R waves in lead AVR. Cardiac ventricular aneurysm 153 FIG. 6a FIG. 6b Legends toFigs6aand6bareonpage 154 1541Hugh R. S. Harley myocardial infarction were men, whereas the sex 2. Acquired ratio in favour of males for myocardial infarction (a) Ischaemic (myocardial infarction) was 25 to 1. (b) Traumatic AGE Most ventricular aneurysms following myo- 1. Accidental wounds cardial infarction occur between the ages of 45 Closed Open and 70 years, but no age is exempt. Robicsek, Dickson, Parke, Daugherty, and Sanger (1966) 2. Surgical wounds reported the case of a baby boy who developed Closed cardiac operations myocardial infarction at the ageof 5 weeks which Open cardiac operations caused an aneurysm of the left ventricle that was (c) Infective successfully excised at the age of 4 years. Of the 1. Rheumatic fever 102 patients of Schlichter et al. (1954) 725% were 2. Syphilis aged between 55 and 74 years, but Schlichter 3. Tuberculosis himself saw a ventricular aneurysm in an infant of 21 months caused by an anomalous left coro- 4. Infective endocarditis, with resultant nary artery originating from the pulmonary artery. myocardial abscess; especially with mycotic coronary arteritis. EXCITING CAUSES The aetiology of ventricular 5. Septic embolus (e.g., in subacute bac- aneurysms was discussed in detail by Schlichter terial endocarditis) et al. (1954) and others. The causes may be classi- 6. Polyarteritis fied as follows: (d) Idopathic 1. Congenital PREDISPOSING FACTORS SYSTEMIC HYPERTENSION Schlichter et al. (1954) found the incidence of systemic hypertension to be 6760% in their series, twice as great as that found by Mintz and Katz (1947), namely 35900, for patients with myocardial infarction but with- out aneurysm, studied in the same hospital and using the same criteria for hypertension. The inci- dence of systemic hypertension found in the aneurysm series (as also in the other series) was higher in women (8644%) than in men (6255%). Only 3 of the 22 women were not hypertensive. In contrast with the figures of Schlichter et al. (1954) are those of Dubnow et al. (1965), who found an incidence of 29% in 80 necropsy cases, and of Gorlin, Klein, and Sullivan (1967), who found hypertension in only 6 out of 24 patients investi- gated clinically. On the basis of their respective findings Schlichter et al. (1954) stressed the importance of systemlic hypertension as an aetio- logical factor in the development of ventricular aneurysms, whereas Dubnow et al. (1965) were unable to draw any conclusions. A high intraventricular pressure would be expected to encourage the development of an aneurysm in a functionless portion of the FIG. 6c ventricular wall, and this is supported by the high aFIdGmSissi6oan,fobr, saurngderyc., shRoawditohgeraanpthesrio(r1l8y.p9.l6a7c)e,daafnteeurryrsem- itnecnsiidoennceinofpaptoisetn-tospedreavtievleopriingghtavneenturriycsumlasr ohfypetrhe- together with moderate enlargement ofthe left ventricle right ventricle after surgery (see iatrogenic andleft atrium. traumatic aneurysms). ....~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.... ~~~~~........ Cardiac ventricular aneurysm 155 DIABETES MELLITUS This is known to have a myocardial infarction. They suggested that the correlation with ischaemic heart disease and is strain caused by these lesions contributed to the common in patients suffering from ventricular development of aneurysm. aneurysms. It occurred in 225% of the patients of Schlichter et al. (1954), in 24 of the 65 patients BED REST Schlichter et al. (1954) found that of of Abrams et al. (1963), and in 16 of the 24 82 patients with relevant details 39% had had no patients of Gorlin et al. (1967). Abrams et al. bed rest after their myocardial infarction, and that (1963) state '. . . a ventricular aneurysm should 317% of them had had bed rest for three weeks be particularly considered in diabetic patients, or less. They considered that these figures were especially men, with cardiomegaly and a history significant, and that a short or absent period of of myocardial infarction'. As in the case of hyper- bed rest predisposed to the development of a tension, Schlichter et al. (1954) found that the ventricular aneurysm. They advised bed rest for incidence of diabetes was higher in women (41%) four weeks or more for all large or transmural than in men (17-5%). Only one of their 22 women infarcts. This view has been quoted by a number had neither hypertension nor diabetes. of subsequent writers on the subject of ventricular aneurysm, but Dubnow et al. (1965) found no VALVE DISEASE Schlichter et al. (1954) found that correlation between lack of bed rest and the 27 of their 102 patients had significant deformities development of an aneurysm in their patients, and of heart valves, an incidence higher than that for Telling and Wooler (1961), after studying pub- .4....................#W- S * i VI I _I I I V2 : V3 AVR -- ; -- - - ~V4 _ tV * . ........;:..^..~~~~~~'S AV .. AVL 41 V5 .. c--tcaa4 AVF _ V6 _ 1, FIG. 7. E.C.G. 15 days after operation (11.10.67). Thechanges are similar to those before the operation, but the segment elevation is lessmarked. aS. 156 Hugh R. S. Harley lished case reports where sufficient detail was AETIOLOGICAL TYPES OF VENTRICULAR ANEURYSM given, came to the conclusion that the hypothesis that inadequate rest was a major cause of CONGENITAL ANEURYSM This is very rare in either aneurysm was not supported by theevidence. More ventricle. Congenital aneurysms of the right ven- than one half of the patients of Dubnow et al. tricle have been reported by Bjork (1964) and by (1965) had had bed rest for three weeks or more. Miller, Lowenthal, Krause, and Rosenblum (1953). The role of the period of bed rest seems to be A congenital aneurysm of the apex of the left open to doubt. ventricle was reported by Bjbrk (1964). This The above analysis suggests, but does not aneurysm was thin-walled and completely separa- prove, that any cause of ventricular stress accom- ted from the remaining part of the left ventricle panying or following panmural infarction of the by a wall of fibrous tissue, but it was full of un- ventricular wall predisposes to the formation of an clotted blood. aneurysm. Thus patients who are afflicted by panmural infarction and who suffer from systemic ANEURYSM CAUSED BY MYOCARDIAL INFARCTION DUE hypertension or valvar disease are, perhaps, pre- TOCORONARYARTERIALDISEASE Myocardial infarc- disposed to the development of an aneurysm of tion accounts for 85% to 9000 of all ventricular the left ventricle. Likewise aneurysms are liable aneurysms (Schlichter et al., 1954; Telling and to develop in the right ventricle after surgery when Wooler, 1961). They are especially likely to occur right ventricular hypertension persists after the after large transmural infarcts associated with operation. Diabetes mellitus appears to be a pericarditis. In all 40 of the necropsy cases common concomitant of ventricular aneurysm. reported by Phares, Edwards, and Burchell (1953) the infarct was transmural. Infarction was the cause of 63 out of the 65 aneurysms reported by Abrams et al. (1963). i:.:::9eiA......rI,..... The majority of ischaemic aneurysms affect the left ventricle. The rarity of ischaemic aneurysm of the right ventricle was stressed by Stansel, Julian, and Dye (1963), who quote Appelbaum and Nicolson (1935) as findting only one in 56 necropsy cases of ventricular aneurysm, Legg (1884) as finding 3 in 90 necropsy cases, and Hall (1903) as finding one in 112 cases. Of the 102 necropsy cases reported by Schlichter et al. (1954), one involved the right ventricle only and three affected both ventricles, whereas all th2 aneurysms in the 80 necropsy cases reported by Dubnow et al. (1965) affected thf left ventricle. Summ,ing these figures of 440 aneurysms due to myocardial ischaemia, only six (144%) were confined to the right ventricle. Most left ventricular aneurysms due to myo- .. cardial infarction occur in the anterior wall or apex of the ventricle (Schlichter et al., 1954; Edwards, 1961 ; Dubnow et al., 1965; Gorlin et al., 1967) in the territory supplied by the anterior descending branch of the left coronary artery (Lillehei, Levy, DeWall, and Warden, 1962; Effler, Westcott, Groves, and Sully, 1963; Cooley, Hallman, and Henly, 1964). According to Effler et al. (1963) this is the only site where a large :..... enough area of muscle replacement by fibrous tssue is compatible with an adequate collateral circulation, and with restriction of infarction to FIG. 8. Section of resected specimen stained with the ventricular wall alone, so allowing both haematoxylin and eosin, showing an 'island' of necrotic survival of the patient and the development of an cardiac musclein dense collagen. x120. aneurysm. In the series of 82 aneurysms occurring Cardiac ventricular aneurysm 157 in 80 necropsy patients studied by Dubnow et al. 100%. This incidence is, I believe, higher than most (1965), 79% of the aneurysms were situated in the physicians realise, perhaps because previously anterior wall or apex of the left ventricle, and 31 there has been little possibility of effective surgical of the 40 aneurysms studied at necropsy by Phares treatment, and the diagnosis was not considered et al. (1953) occurred at the same sites (Edwards, to be of great importance from a therapeutic 1961). standpoint. The incidence of ventricular aneurysm after myocardial infarction reported in the literature TRAUMATIC ANEURYSMS Traumatic aneurysm varies between 355% and 38% (Schlichter et al., may be true or false (vide infra). Such aneurysms 1954; Lillehei et al., 1962; Cooley et al., 1964; are very rare in either ventricle after accidental Dubnow et al., 1965). This wide variation in trauma, whether open or closed (Joachim and reported frequency depends upon the type of Mays, 1927; Lyons and Perkins, 1958; Kerr, study (necropsy or clinical) and on the definition Wilcken, and Steiner, 1961 ; Stansel et al., 1963; of an aneurysm (Dubnow et al., 1965). Schlichter Panday, Parulkar, Kelkar, and Sen, 1965). Harken et al. (1954) found an incidence of ventricular (1946) found no aneurysm among 56 patients with aneurysm at necropsy of 15% among 2,273 cases war wounds close to the heart, even though in 13 of myocardial infarction, and in 20% of their own instances the missile was found within a cardiac 512 cases of infarction. Abrams et al. (1963) chamber. Aneurysms following closed injuries found a necropsy incidence of aneurysm of 1244% have been reported by Bright and Beck (1935) and in 508 cases of infarction and.Dubnow et al. Barber (1944). A calcified aneurysm of the left (1965), using the definition of a ventricular ventricle following a stab wound was reported by aneurysm given by Edwards (1961), one of 3 5% Lyons and Perkins (1958), and an aneurysm of in 2,293 necropsies. the left ventricle following its accidental incision All the reported figures for the incidence of during the exposure of the heart for open cardio- ventricular aneurysm after myocardial infarction, pulmonary resuscitation in a case of cardiac except those of Dubnow et al. (1965), are 5% or arrest was reported by Panday et al. (1965). higher, and more than one half of them exceed Vasiljevic, Antic, Tomic, Anojcic, and Prokic FIG. 9. Radiographfour months after excision ofthe aneurysm (22.1.68). The heart ismuch smallerandthere isnoevidenceofleft ventricularfailure.