Twenty-three consecutive patients undergoing operation for left ventricular aneurysm are described with analysis of clinical and laboratory data obtained before and after operation. The reliability of various diagnostic methods is discussed. Five patients died in the perioperative period. Seven further patients have died during follow-up, 5 of recurrent myocardial infarction. The indications for operation are outlined with discussion of the benefits and limitations of current surgical treatment. It is felt that ventricular aneurysmectomy is indicated in a carefully selected group of patients. Though effects of surgical treatment on longevity cannot be completely evaluated, the status of the remaining coronary circulation appears to have an important influence on long-term survival.Though ventricular aneurysm was first described by John Hunter (I757), this condition has come to be clinically recognized as an important complication of myocardial infarction only in relatively recent times with the advent of improved methods of diagnosis. Modem cardiac surgical techniques have made curative treatment possible, and reports of large numbers of patients successfully treated by operation have appeared (Favaloro et al., i968; Cooley and Hallman, I968; Petrovsky, I966). Proper selection of patients for ventricular aneurysmectomy requires a detailed knowledge of the clinical course of patients with this condition and an understanding of the reliability of the various diagnostic methods applied to these patients. Surgical morbidity and mortality, and the results of long-term follow-up must be analysed. We have examined these features in 23 consecutive patients who underwent operations for ventricular aneurysm. Patients and methodsThe case records of 23 consecutive patients undergoing operation for ventricular aneurysm at the Hammersmith Hospital during the period I961-1970, inclusive, were reviewed. The clinical histories, course, findings on physical examination, electrocardiographic tracings, and other ancillary data were analysed in detail. Haemodynamic and angiographic findings at cardiac catheterization and selective coronary arteriography were reviewed. Findings at the time of operation were recorded. Details of postoperative follow-up on all 23 patients up to the time of writing were analysed. These observations and their relation to the available published material form the basis of this report. Unless otherwise indicated, Edwards' (I96I) definition of ventricular aneurysm as 'a protrusion of a localized portion of the external aspect of the left ventricle beyond the remainder of the cardiac surface, with simnultaneous protrusion of the cavity as well' will be applicable throughout this report. ResultsAge and sex Table i shows the age and sex distribution of the entire group of 23 patients. The ages listed are those at the time of operation. The mean age of all patients was 5i' years, with over half the patients in the age range 50-59. Only 2 patients were female, giving a male to female ratio of io 5: I.

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Ventricular function was evaluated in 18 patients prior to left ventriculography and selective coronary arteriography. Simultaneous left ventricular pressure (catheter-tip manometer) and dP/dt were recorded at resting heart rates and during tachycardia induced by right atrial pacing. Pressure-velocity curves were constructed from which V max and maximum measured contractile element velocity (max V CE ) were obtained. V max and max V CE initially increased with pacing-induced tachycardia in 17 of the 18 patients. Eight patients developed evidence of myocardial ischemia during atrial pacing. During the period of myocardial ischemia there was a decrease in V max and max V CE in all eight patients despite constant or increasing heart rate. In the 10 patients who did not develop evidence of myocardial ischemia with pacing-induced tachycardia, V max and max V CE continued to increase or remained constant with increasing rate. Peak left ventricular dP/dt increased coincident with the onset of myocardial ischemia in six of eight patients despite a fall in V max and max V CE in all eight patients during the ischemic period. A highly significant difference was demonstrated between V max values of patients with normal ejection fractions and patients with low ejection fractions, both at rest and during pacing-induced tachycardia.

The fifth case of arteriovenous fistula following nephrectomy for tuberculosis is presented. It is important to consider an arteriovenous communication in cases of unexplained congestive heart failure, particularly when blood pressure findings suggest arteriovenous shunting. The importance of the history of nephrectomy and findings of a loud bruit upon auscultation of the abdomen is evident. Diagnosis is established by selective renal angiography. The preferred treatment is complete excision of the fistulous communication.