Restoring Ventricular Geometry: Left Ventricular Reconstruction in a Patient with a Giant Left Ventricular Aneurysm and End-Stage Heart Failure

Figures

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  Figure 1. Chest radiographs obtained before and after surgical ventricular reconstruction. (A) Preoperative chest radiograph demonstrating marked cardiomegaly, bilateral pleural effusions, and pulmonary vascular/interstitial congestion consistent with advanced congestive heart failure. An implantable cardioverter-defibrillator (ICD) is visible in the left pectoral region. (B) Early postoperative chest radiograph showing a reduction in cardiac silhouette size and improvement of pulmonary congestion following surgical treatment.

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  Figure 2. Preoperative and postoperative transthoracic echocardiography. (A) Apical four-chamber view demonstrating a giant post-infarction left ventricular aneurysm associated with massive ventricular dilatation (LVEDV 1103 mL). (B,C) Early postoperative apical four-chamber and two-chamber views showing successful ventricular restoration with recovery of a more physiological left ventricular cavity shape and a substantial reduction in LV end-diastolic volume (LVEDV 165 mL, biplane Simpson method).

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  Figure 3. Preoperative cardiac magnetic resonance imaging (CMR). (A) Cine images demonstrating a giant post-infarction left ventricular aneurysm involving the apical and anterior segments, associated with severe left ventricular dilatation and adverse remodelling. (B) Late gadolinium enhancement sequences showing extensive transmural scar formation of the aneurysmal wall and partially organized mural thrombus. A discontinuity within the aneurysmal wall with a thin overlying tissue layer is visible, raising suspicion for a chronic contained free-wall rupture.

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  Figure 4. Intraoperative images illustrating surgical ventricular reconstruction. (A) Giant left ventricular apical aneurysm exposed through median sternotomy, demonstrating severe ventricular enlargement and distortion of normal cardiac geometry. (B) Opening of the aneurysmal sac, revealing a large aneurysmal cavity containing organized mural thrombotic material. (C) Endoventricular inspection after thrombectomy, showing the transition zone between viable myocardium and fibrotic scar tissue. A sizing balloon is positioned within the residual left ventricular cavity to guide ventricular reconstruction and restoration of an appropriate ventricular volume and geometry. (D) Completion of surgical ventricular reconstruction using endoventricular circular purse-string plication of the scar–viable myocardium interface followed by aneurysm exclusion and linear closure, restoring a more physiological left ventricular configuration.