Left ventricular aneurysm

Background

• thin/fibrotic wall with no/necrotic muscle that is akinetic or dyskinetic (paradoxical ballooning)

Causes

• Majority: healed transmural MI (anterior most common)
• Rare: HOCM, Chagas

Clinical Features

• Can be asymptomatic
• History of MI
• Angina, shortness of breath/DOE, CHF sx
• Mitral regurgitation murmur, S3/S4

Differential Diagnosis

• Left Ventricular Pseudoaneurysm

Evaluation

• CXR: prominent left heart border, calcified aneurysm
• TTE, LV angiography, cardiac MRI
• ECG: persistent characteristic ST elevation after MI
• Strongly suspect STEMI if:
  • Symptomatic
  • No q waves present (LV aneurysm typically produces significant q waves)
  • Evolving changes on serial ECG
  • Reciprocal changes
• Consider two rules to differentiate
  • Rule 1
    • If (Sum of T-wave amplitudes in V1-V4) divided by (Sum of QRS amplitudes in V1-V4) > 0.22
    • Suggestive of STEMI, with ~87% accuracy
  • Rule 2
    • If any lead in V1-V4 has T-wave amplitude to QRS amplitude ratio > 0.35
    • Suggestive of STEMI, with ~89% accuracy

Management

• Be sure to rule out acute or subacute acute coronary syndrome

Medical Therapy (first line)

• Afterload reduction (ACEI)
• Antianginal (Nitro)
• Anticoagulation (if LV thrombus)

Surgical Therapy

• Aneurysmectomy and CABG (and possible valve repair) if ventricular arrhythmias and/or HF refractory to medical therapy

Complications

• Heart failure (LV aneurysm steals CO)
• Angina (increased O2 demand)
• Ventricular arrhythmias (LV stretch/scarring)
• LV thrombus (50% of time), arterial embolism (stroke)
• LV rupture (rarely occurs in mature LVA because of dense fibrosis)

See Also

Myocardial Infarction Complications

Authors

Ross Donaldson