Atrial septal aneurysm as a cause of abnormal left atrial flow: an echocardiographic study

Atrial septal aneurysms, although rare, are being found with an ever increasing frequency through the technology of two-dimensional echocardiography. In this article, we report the identification of an atrial septal aneurysm and abnormal systolic flow toward the transducer and mitral valve by use of two-dimensional echocardiography with pulsed-wave Doppler capability.

[Scintigraphic diagnosis of postinfarction left ventricular aneurysm and the prediction of the residual left ventricular function after aneurysmectomy using ECG gated blood pool SPECT]

The diagnostic accuracy of ECG gated blood pool SPECT (blood pool SPECT) for detecting and quantify postinfarction left ventricular aneurysm (LVA) was assessed in 49 patients with myocardial infarction and 15 control subjects. LVA, which was detected in 35 of 49 patients, was defined as a regional protrusion through a cardiac cycle in contrast ventriculography and as a non-contracting segment with a markedly delayed phase angle in the tomographic functional images derived from phase analysis. The blood pool SPECT technique showed a high sensitivity (100%), specificity (78.6%) and accuracy (93.3%) for detecting LVA and was very useful for precisely determining LVA location and sizing contractile and non-contractile volume of left ventricle in patients with LVA. Furthermore, left ventricular ejection fraction (LVEF) after the excision of LVA was predicted using preoperative pool SPECT images in 9 patients. The predicted LVEF was closely correlated with the measured LVEF after the operation (y = 1.09x-4.37, r = 0.87, p less than 0.01). Thus, gated blood pool SPECT can be a useful non-invasive technique not only for detecting and quantifying left ventricular aneurysm but also for predicting a residual left ventricular function after aneurysmectomy.

[Postextrasystolic potential in patients with a left ventricular postinfarct aneurysm]

The author analyzes the effect of postextrasystolic potentiation of contraction of the asynergic regions of the myocardium in 18 of 34 patients with postinfarction aneurysm of the left ventricle evaluated by contrast ventriculography. There was a statistically valid increase of the extension of the zones of hypokinesia due to reduction of the relative length of akinetic regions as compared with data of control contractions, a significant rise of reduction of the sizes of hypokinetic zones, increase of the fraction of ejection of the contractile segment in the general fraction of ejection. It is recommended to use the effect of postextrasystolic potentiation of contraction on the function of asynergic regions of the myocardium with the purpose of assessment of their vitality, determination of resection borders and expediency of their revascularization in the course of aneurysmectomy.

Improvement of left ventricular aneurysm after myocardial infarction: report of three cases

We report on the disappearance of a left ventricular aneurysm after myocardial infarction in three cases. Coronary blood flow was restored by spontaneous recanalization in two cases and by angioplasty in one case. When the aneurysm was observed, the findings in these cases were (1) no or limited abnormal Q wave in surface electrocardiography, (2) total or subtotal stenosis of the proximal coronary artery without adequate distal filling through collaterals, (3) no ST shift in exercise electrocardiography, and (4) decreased but not absent thallium-201 uptake in myocardial scintigraphy. In Cases 1 and 2, respectively, 3 years and one year and 8 months after the myocardial infarction, an anginal episode occurred and the ventricular aneurysm disappeared. In Case 3, the aneurysm disappeared after coronary angioplasty. These cases suggest that even without a demonstration of reversible ischemic myocardium and/or severe stenosis without distal filling through collaterals, the myocardium presenting a ventricular aneurysm would be hibernating. These cases were also informative about the detection of hibernating myocardium.

[Left ventricular pseudoaneurysm. The dynamics and flow patterns analyzed by Doppler echocardiography]

A patient with antecedents of ischemic cardiopathy is presented. Echocardiographic exploration revealed the presence of an accessory cavity in connection with the left ventricle behind the basal segment of the posterior left ventricular wall, the characteristics of which were compatible with a ventricular pseudoaneurysm. The Doppler study (both conventional and color coded) allowed us to determine the multiphasic characteristics of the flow between both cavities, and its relation with the variations of volume of the same, as well as with the transmitral and aortic flows. The filling of the pseudoaneurysm was observed to begin before initiation of the ejection through the aorta. Initiation of emptying towards the left ventricular cavity took place in the late systole, and there was a new flow inversion towards the pseudoaneurysm in the early diastole coinciding with the rapid ventricular filling, and therefore before producing the atrial contraction.

Reduced high harmonic power spectra in patients with old myocardial infarction

Acceleration of blood flow ejected from the ventricle into the aorta and the hydraulic power state of blood flow in the aorta may be affected by asynchronous or locally depressed contraction of the left ventricle as well as by arterial impedance. In order to evaluate the effect of an infarcted heart on the hydraulic power state of blood flow, the aortic input impedance spectrum and the hydraulic power spectrum were calculated from simultaneous recordings of pulsatile aortic pressure and flow velocity at the aortic root in 6 normal controls (group 1), 6 patients with old myocardial infarction (OMI) without aneurysm (group 2), and 6 patients of OMI with aneurysm (group 3). The ratios (Rh) of power in high harmonics to that of fundamental harmonics, that is, Rh = (E2 + E3 + ...E10)/E1, where E represents hydraulic power and the numbers represent harmonic numbers, were 0.64 +/- 0.17, 0.23 +/- 0.09, and 0.22 +/- 0.10 in groups 1, 2, and respectively (p less than 0.001 between groups 1 and 2; p less than 0.001, between groups 1 and 3). As the acceleration of ejecting flow of blood by the left ventricle is inversely related with arterial impedance, Rh will be also inversely related with arterial impedance. Then, the product of Rh and the characteristic impedance (Zc) would be an indicator of the left ventricular contractility. In fact, the products were 64 +/- 15, 32 +/- 14, and 31 +/- 13 dyne.sec.cm-5 in groups 1, 2, and 3 respectively (p less than 0.005, between groups 1 and 2; p less than 0.005, between groups 1 and 3). These results suggest that asynchronous or locally depressed contractions of the left ventricular wall are closely related to depressed Rh and further to depressed values of the products of Rh and Zc. It is concluded that analysis of the power spectrum of blood flow in the root of the aorta provides information of the left ventricular contractility in connection with arterial impedance.

Natural history of chronic left ventricular aneurysm; a population based cohort study

In order to evaluate the morbidity and mortality of chronic left ventricular aneurysm a population based cohort study was carried out. All cardiac catheterizations performed in Iceland during the years 1983-1985 were examined (n = 1261). Sixty seven patients with left ventricular aneurysm defined as: (1) normal diastolic contour with segmental dyskinesis (n = 6), (2) abnormal diastolic contour with (a) akinetic (n = 36) or (b) dyskinetic (n = 25) segments in systole, were included. Sixty seven patients with normal diastolic contour and akinetic segments in systole served as controls. The groups had similar mean age, sex ratio, number of diseased vessels and left ventricular end diastolic pressure. Mean ejection fraction was significantly lower in the aneurysm group (46 vs 56%, p = 0.00005). Collaterals were detected significantly more often in controls (88 vs 72%, p = 0.03). At follow up in 1989, 19 in the aneurysm group had died as compared to 12 in the control group. Life table analysis revealed significant differences between survival curves. The relative risk ratio was 2.18 with 95% confidence interval of 1.00-4.74 (p less than 0.05). However, when the amount of myocardial damage was taken into account the differences in survival were no longer statistically significant (relative risk ratio 1.77 with 95% confidence interval of 0.79-3.99). We conclude that the reduced survival probability of patients with chronic left ventricular aneurysm in comparison to controls with akinetic scars is accounted for by the more extensive myocardial damage and not by the presence of aneurysm per se.

Left ventricular aneurysm: clinical and hemodynamic data

Clinical and hemodynamic data of 30 patients with left ventricular aneurysm (27 men, 3 women, mean age 54.9 years) were compared with those of 30 patients with previous myocardial infarction and segmental hypo- or akinesis (28 men, 2 women, mean age 51 years). In each group, 10 patients were affected by one-, two-, or three-vessel disease. A semiquantitative evaluation of collateral coronary circulation showed no significant differences between the two groups. Mean end-diastolic volume was higher in patients with left ventricular aneurysm (p less than .025, less than .05, and less than .001 in 1-, 2-, and 3-vessel disease, respectively) and ejection fraction was lower only in patients with one-, (p less than .001) and two- (p less than .05) vessel disease in comparison with patients without left ventricular aneurysm. No significant difference was evidenced in basal or isometric exercise end-diastolic pressure. The incidence of thrombosis detected by ventriculography was higher in patients with left ventricular aneurysm (33.3 vs. 6.6%). The mean duration of follow-up was 20.7 months in patients with left ventricular aneurysm and 20.6 in the control group. No significant difference was found either in mortality or in reinfarction rate as far as incidence and severity of angina. The incidence of congestive heart failure was more evident, but not significant in patients with left ventricular aneurysm. One embolic episode was present in one patient with aneurysm and intraventricular thrombosis. Left ventricular performance is influenced by an aneurysm when a limited coronary compromise is present (one- and two-vessel disease) while it is not affected in the case of a coexisting three-vessel disease.

Simulated left ventricular aneurysm and aneurysm repair in swine

Patch reconstruction of left ventricular aneurysm may be superior to linear closure, but this hypothesis has not been tested experimentally. Accordingly, six anesthetized domestic pigs were instrumented to measure regional left ventricular wall thickening, stroke volume, systolic left ventricular pressure, and myocardial oxygen consumption. With total bypass and cardioplegia, a 6 by 8 cm Dacron patch was inserted into the anteroapical left ventricle. Simulations were as follows: left ventricular aneurysm, patch open; patch reconstruction, 50% patch plication; standard repair, ventriculotomy edges approximated. Global function, from stroke work (stroke volume x integral of left ventricular pressure)-left ventricular end-diastolic pressure curves, was depressed in all three simulations compared with control. A tendency for stroke work to be greater for standard repair than for left ventricular aneurysm and patch reconstruction at higher preloads was not statistically significant. Mechanical efficiency, from stroke work/myocardial oxygen consumption (joules per milliliter oxygen per beat), was 2.43 +/- 0.52 (mean +/- standard error of the mean) (control), 2.22 +/- 0.94 (standard repair), 1.27 +/- 0.39 (patch reconstruction), and 1.09 +/- 0.37 (left ventricular aneurysm) (no significant differences). Regional work was calculated as regional left ventricular wall thickening x integral of left ventricular pressure. The slope of the regional work-end-diastolic wall thickness relation decreased in the posterior wall 14.0 +/- 2.9 (control) versus 8.4 +/- 2.0 (left ventricular aneurysm), 6.9 +/- 1.4 (patch reconstruction), and 7.4 +/- 1.4 (standard repair) (p less than 0.05). In the anterior wall, contractility did not change significantly (7.4 +/- 1.2, control; 7.8 +/- 2.7, left ventricular aneurysm; 5.0 +/- 0.4, patch reconstruction; and 5.3 +/- 0.4, standard repair). Decreased end-diastolic wall thinning anteriorly suggested tethering. These results in the normal left ventricle suggest that patch ventriculoplasty is of no greater benefit than linear repair. Either repair may impede function of adjacent myocardium through restriction of regional diastolic lengthening.

Relative risks of left ventricular aneurysmectomy in patients with akinetic scars versus true dyskinetic aneurysms

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%, 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.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pseudoaneurysm of the left ventricle. Description of a clinical case]

The paper describes a case of pseudoaneurysm of the left ventricle following an earlier operation to close a post-infarction interventricular defect. The nosological entity is described paying particular attention to preoperative functional tests and intraoperative anesthesiological procedures. The careful monitoring of refilling pressure and cardiac load represents an essential for the correct infusion of drugs and optimal volemic refilling.

[Left ventricular aneurysmectomy after myocardial infarction--comparative study between true aneurysms and functional aneurysms]

Postinfarction left ventricular aneurysms are pathophysiologically divided into true, functional and false aneurysm. On 14 patients treated by aneurysmectomy, we studied the difference of pre- and post-operative cardiac function between true aneurysms (9 patients) and functional aneurysms (5 patients). The aneurysm area, which is expressed as the end-diastolic perimeter (akinetic or dyskinetic area/left ventricular silhouette), was 51.6 +/- 7.7% in the true aneurysms versus 35.7 +/- 6.0% in the functional aneurysms. Preoperatively, patients with a true aneurysm had a more severe clinical status than those with a functional aneurysm (Six of nine patients with a true aneurysm were in New York Heart Association functional class III or IV). Postoperatively, all patients except one with a true aneurysm and one with a functional aneurysm improved in clinical status. Nonaneurysmal EF, that is the function of the nonaneurysmal left ventricle, has a significant correlation to postoperative LVEF (r = 0.57, p less than 0.05). Nonaneurysmal EF was 54 +/- 4% in the true aneurysm group versus 51 +/- 16% in the functional aneurysm group. LVEF improved significantly (p less than 0.05) from 31 +/- 11% preoperatively to 55 +/- 10% postoperatively in the group of true aneurysm, but did not improved significantly from 43 +/- 12% to 50 +/- 9% in the functional aneurysm group. The postoperative akinetic area was 8.1 +/- 9.1% in the true aneurysm group versus 17.8 +/- 11.5% in the functional group. We conclude that larger and more adequate resection of aneurysms improves the cardiac function in the true aneurysm group more than in the functional aneurysm group.

An association between left axis deviation and an aneurysmal defect in children with a perimembranous ventricular septal defect

Conspicuous left axis deviation was found in two thirds (27 patients) of 44 children with a perimembranous ventricular septal defect, echocardiographic signs of apposition of the septal tricuspid valve leaflet, and an aneurysm of the membranous septum. In 10 patients earlier electrocardiograms did not show left axis deviation; this feature appeared when the aneurysm of the membranous septum was first seen on the echocardiogram. None of the 44 controls with perimembranous ventricular septal defect but without an aneurysm had left axis deviation. This study suggests that the appearances of conspicuous left axis deviation in a patient with ventricular septal defect indicate a spontaneous reduction in the defect by apposition of the septal tricuspid valve leaflet and by the formation of an aneurysm of the membranous septum.

Abolition of electrocardiographic pattern of left ventricular aneurysm by posterior myocardial infarction

We report a patient who presented with prominent gastrointestinal symptoms in whom a confident clinical diagnosis of acute posterior myocardial infarction was facilitated because the fresh electrocardiographic changes of true posterior myocardial infarction abolished the old pattern of left ventricular aneurysm. This interesting electrocardiographic phenomenon has not, to our knowledge, been previously reported.

Relation between ventricular late endocardial activity during intraoperative endocardial mapping and low-amplitude signals within the terminal QRS complex on the signal-averaged surface electrocardiogram

Noninvasive recording of ventricular late potentials and intraoperative endocardial mapping at 36 sites were performed in 24 patients with left ventricular aneurysm and drug-resistant sustained ventricular tachycardia due to coronary artery disease. Their mean age was 55 +/- 8 years. Mean ejection fraction was 28 +/- 12%. For detection of late potentials on the signal-averaged QRS complex, 3 different algorithms were used. Late potentials were found in 54, 67 and 67% of the patients, respectively. In patients with a late potential on the signal-averaged electrocardiogram (ECG), delayed local activation (greater than 40 ms beyond the QRS complex on the intraoperative surface ECG) was recorded at 5.5, 5.5 and 5.6 endocardial sites. In patients without a late potential, this type of delayed local activation was detected at 2.4, 1.1 and 0.9 of 36 endocardial sites, respectively (p less than 0.05; p less than 0.01; p less than 0.002). The mean delay of local endocardial activity was 38, 35 and 37 ms in patients with a late potential on the body surface recording versus 20, 19 and 11 ms, respectively, in patients without a late potential (p less than 0.05; p less than 0.05; p less than 0.002). There was no correlation between the duration or amplitude of the late potential, if present, and the number of endocardial sites exhibiting delayed activity (r = -0.23, r = -0.05, r = 0.21; correlation not significant for each) or the mean duration of the endocardial delayed activity (r = -0.25, r = -0.14, r = -0.07; correlation not significant for each). These results indicate that the presence of late potentials on the signal-averaged surface ECG is related to the mean duration of endocardial late activity as well as to the number of endocardial sites exhibiting a given degree of delayed activation. Thus, it is dependent on the mass of slowly activated tissue. However, a direct conclusion from the duration or the amplitude of a late potential to the amount of delayed activation or the extent of endocardial time delay does not seem possible.

Myocardial infarction and biventricular free-wall rupture with shunting through a false aneurysm

A 65-year-old man presented with acute inferior myocardial infarction and received thrombolytic therapy with clinical evidence of coronary arterial recanalisation. Recovery was uncomplicated until- the eighth day when he experienced recurrent chest pain with evidence of reinfarction in the same territory. This was associated with the development of a pansystolic murmur and cardiogenic shock. Cardiac catheterisation showed right coronary arterial occlusion and inferior infarction with a false aneurysm and a left-to-right shunt (shunt ratio 2.5:1). Surgery confirmed the formation of a false aneurysm caused by rupture of the free walls of both ventricles. Importantly, however, the interventricular septum was intact and the left-to-right shunt was through the false aneurysm itself. This is the first report of biventricular free-wall rupture with shunting through a false aneurysm treated successfully by surgery.

Profile of submitral left ventricular aneurysms in Indian patients

Annular subvalvar aneurysms of the left ventricle initially described from Nigeria are considered to be rare in India. We report 6 such cases studied clinically and by noninvasive and invasive investigations during the last 8 years. In 4 cases morphologic documentation was available at surgery or autopsy. The clinical picture was dominated by congestive cardiac failure and mitral regurgitation and most of the patients were young. Echocardiographic studies provided the precise noninvasive diagnosis by demonstrating large aneurysms arising below the posterior mitral leaflet. In one case the submitral left ventricular aneurysm extended into the left atrium. The mortality was high in unoperated cases and operative repair under cardiopulmonary bypass is the most appropriate management.

[Aneurysm of interauricular septum associated with mesosytolic click]

An echocardiographic study was performed to a patient with symptoms of cardiac failure and midsystolic click confirmed by phonocardiography. The echocardiograms suggested an incipient dilated myocardiopathy and also atrial septal aneurysm. We report the relationship between midsystolic click and atrial septal aneurysm.

Natural course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defect

Atrial septum aneurysm (ASA), usually involving the region of the fossa ovalis, has rarely been described in children. In this study, the incidence and natural course of this anomaly were prospectively evaluated in 3,500 children referred for echocardiographic examination. ASA was found in 35 patients, 19 female and 16 male (1.0%). Patients were 6 years of age or younger at the time of diagnosis and 18 were neonates. None of the 750 children with normal echocardiograms had ASA. The most common associated lesion was atrial septal defect (ASD), which occurred in 24 of the 35 patients (69%). Other associated cardiac lesions were ventricular septal defect in 10, pulmonary stenosis in 5, patient ductus arteriosus in 4 and coarctation or interruption of the aorta with subaortic membrane in 2. No clinical complications were associated with ASA. Six patients with complex heart disease died. When associated with ASD, the direction of the ASA motion and that of the shunt found by Doppler echocardiography were similar. Fourteen patients with ASD were followed for 0.5 to 4 years. In 8 the ASD closed and in 6 the ASA disappeared. In 6 patients the ASD and ASA persisted until the end of the follow-up (p less than 0.01). Thus, the incidence of ASA in children in this series was higher than previously presumed and usually was associated with other cardiac anomalies, mainly ASD. In children, ASA tends to disappear with age and may have a role in spontaneous closure of associated ASD.

Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm

We recently repaired six large ventricular aneurysms using a technique that emphasizes restoring function rather than excising diseased tissue, or endoaneurysmorrhaphy. An elliptical woven Dacron patch is tailored to fit the defect in the left ventricular wall, making the length and width conform to the normal left ventricular volume. In each of our cases, use of this technique allowed prompt recovery and restoration of ventricular function.