Surgical treatment of postinfarction left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm from myocardial infarction is rare and is associated with a high risk of rapid enlargement and rupture. The purposes of this study were to describe its clinical presentation, assess the accuracy of diagnostic imaging modalities, and determine operative and late surgical results.

From January 1986 through December 2001, 30 patients aged 50 to 85 years (mean, 68; 70% male) underwent left ventricular pseudoaneurysm repair. Two surgical approaches were used: primary repair (n = 5, 17%) and patch closure (n = 25, 83%). Twenty-one patients (70%) had concomitant procedures, including coronary revascularization (n = 17, 57%) and mitral valve surgery (n = 9, 30%); 8 patients (29%) underwent emergent surgery. Clinical presentation, preoperative imaging data, and surgical outcomes were abstracted from medical records or obtained by patient follow-up.

The most common clinical presentations were heart failure (n = 22, 73%) and angina (n = 11, 41%). Pseudoaneurysm was rarely suspected at clinical presentation. Contrast ventriculography was diagnostic in 54% of patients in whom it was performed, as opposed to 97% for two-dimensional echocardiography (p = 0.2). Postoperative intra-aortic balloon pump was required in 7 patients (23%). Hospital mortality was 20%, and late survival was 73%, 59%, and 45% at 1, 5, and 8 years, respectively.

Left ventricular pseudoaneurysm should be suspected in postinfarction patients with unexplained heart failure. Echocardiography is usually diagnostic and is superior to ventriculography. The surgical mortality rate is elevated in this complex patient population. Long-term survival is also poor, mainly because of underlying ischemic cardiomyopathy.