Prospective correlative study of ventricular aneurysm: Mechanistic concept and clinical recognition

Abstract Ventricular aneurysm was recognized by cineventriculography in twenty-four patients with coronary heart disease. They were studied prospectively, with correlation of clinical, apexcardiographic, electrocardiographic, x-ray and cine coronary arteriographic and cineventriculographic data. These data were further analyzed in relation to findings noted in sixteen of these patients either at necropsy or during surgery. Motion disturbances in the region of the aneurysm were considered to be expressions of ventricular asynergy and fell into two groups: akinesis, or local lack of wall motion, in sixteen; and dyskinesis, or local paradoxical systolic expansion, in eight. Contrary to expectation, aneurysms were composed solely of thin-walled fibroses in only seven of sixteen directly observed patients. Seven additional patients had mixed "full thickness" muscle and fibrosis, and two showed aneurysmal bulging of viable perfused myocardium. The majority of aneurysms were located either at the apex or on the anterior surface, with variation in size from 10 to 50 per cent of estimated left ventricular surface area. The correlation was good between directly observed and cineventriculographic estimates of site, approximate size and type of asynergy of aneurysm. No aneurysm occurred without severe involvement (usually occlusion) of the major local artery. The electrocardiographic site of prior myocardial infarction, when present, correlated well with the site of aneurysm. Laboratory evidence of congestive failure was obtained more frequently than clinical evidence of failure. There was no necessary relationship between the presence of heart failure and cardiac enlargement, nor did a normal or nearly normal sized heart preclude failure. On palpation, a diffuse, displaced or double left ventricular impulse without other evident cause was a reliable clue to aneurysm in eight cases, and the impulse was suspicious in another five. Apexcardiography revealed abnormal findings in another three subjects with normal precordial impulses. This consisted of a late systolic bulge. The cardiac roentgenogram indicated a rough relationship between the size of the heart and the size of the aneurysm, estimated by cineventriculogram or by direct observation, but there were frequent startling exceptions. Localized bulges or bumps in any projection, no matter how minor, often served as useful clues. The roentgenogram was truly diagnostic in only five subjects, but was at least suspicious in an additional ten. The electrocardiogram showed ST-T segment elevation in sixteen of twenty-four patients, but the two-step exercise test was required to elicit such elevation in four of the sixteen subjects. This indicates the important role of exercise in discovering aneurysms unsuspected from electrocardiograms. Cumulatively, there was some important objective clinical clue suggestive of aneurysm in nineteen of twenty-four patients. On the other hand, in only nine of the nineteen could a reasonable quantitative estimate be made. In the other ten the size of the aneurysm was grossly underestimated clinically. Inferior and lateral aneurysms proved most difficult to diagnose clinically and usually depended on ventriculography for recognition. Seven of twenty-four patients died during observation, but only one died of congestive failure. The majority succumbed to recurrent infarction.