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Left ventricular aneurysm
From WikEM
Contents
Background
- thin/fibrotic wall with no/necrotic muscle that is akinetic or dyskinetic (paradoxical ballooning)
Causes
Clinical Features
- Can be asymptomatic
- History of MI
- Angina, shortness of breath/DOE, CHF sx
- Mitral regurgitation murmur, S3/S4
Differential Diagnosis
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[1]
- 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
- Rule 1
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
- ↑ Klein LR, Shroff GR, Beeman W, and Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med. 2015 Jun;33(6):786-90.
