Relative Risks of Left Ventricular Aneurysmectomy in Patients With Akinetic Scars Versus True Dyskinetic Aneurysms

Couper, Gregory S. MD
Bunton, Richard W. MD
Birjiniuk, Vladimir MD
Disesa, Verdi J. MD
Fallon, Maureen P. BA
Collins, John J. Jr. MD
Cohn, Lawrence H. MD

Harvard Medical School and Brigham and Women's Hospital, Boston, Mass.

Address for correspondence: Gregory S. Couper, MD, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Circulation 82(5):p IV-256, November 1990.

From 1971 to 1988, 303 patients underwent left ventricular aneurysm resection. We analyzed preoperative and procedure-related variables to ascertain risk factors for surgery. A distinction was made between akinetic and dyskinetic aneurysms to assess potential relation with postoperative outcome. Indications for surgery were arrhythmia in 20 patients, congestive heart failure in 81, angina in 133, congestive heart failure and angina in 42, and other combinations in the remaining 27 patients. The left ventricular aneurysm was dyskinetic in 180 patients and akinetic in 121. Risk factors and surgical procedures were similar in both groups. Left ventricular ejection fraction was less than or equal to 30% in 98 patients. Coronary bypass grafting was performed in 269 patients, with an average of 2.3 grafts per patient. Mitral valve replacement, the most common concomitant procedure, was performed in 16 patients. Intra-aortic balloon assist was required postoperatively in 47 patients. Overall operative mortality was 13% (38 patients) and was due to low cardiac output in 23 patients and arrhythmia in 12 patients. Univariate and multivariate analyses related early mortality to New York Heart Association functional classification of heart failure, the predominant indications of arrhythmia or congestive heart failure, left ventricular ejection fraction less than or equal to 30%1, the need for intra-aortic balloon support, and the excision of an akinetic (18%) rather than dyskinetic (8%) left ventricular aneurysm. Over a follow-up period averaging nearly 5 years, the actuarial survival at 5 years was 63% in the dyskinetic group and 51% in the akinetic group. Respective probabilities of 10-year survival were 36% and 30%to. Higher operative mortality after aneurysmectomy for akinetic scars raises the possibility of inadequate residual ventricular volume and resultant low cardiac output syndromes. Alternative methods of ventricular reconstruction with patch ventriculoplasty might maintain better ventricular dimensions and geometry. A critical analysis of ventricular dimensions and function needs to be done to correlate these speculated benefits with changes in operative mortality.