A consecutive series of 97 patients with a left ventricular aneurysm (LVA) was evaluated for aneurysmectomy. A wide range in left ventricular (LV) function was found. Angina pectoris was the primary indication (51%) in 55 patients who were operated upon, whereas poor LV function was the main reason (67%) for rejecting surgery in 42 patients. Operative mortality was 9% and exclusively seen in patients with congestive heart failure and/or sustained ventricular arrhythmias. Functional status improved from (NYHA) 3.0 +/- 0.7 to 2.3 +/- 0.5 (P less than 0.0001) after surgery, while haemodynamics at rest remained unchanged. In the medically treated group, 10 patients underwent heart transplantation without mortality during follow-up. Of the remaining 32, 7 had died (22%), all with severely impaired LV function. The best prognosis with no deaths was observed in the 14 medically treated patients with moderate complaints and well preserved LV function. Those with poor LV function and/or ventricular arrhythmias had a poor prognosis whether they were treated medically or by conventional aneurysm surgery. In young selected patients with a short life expectancy, heart transplantation may represent an alternative.