Left ventricular aneurysm: Difference between revisions
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==Background== | ==Background== | ||
* | [[File:Heart left ventricular aneurysm sa.jpg|thumb|Left ventricular aneurysm: thinned wall in upper right of picture (short axis view)]] | ||
[[File:Heart lv aneurysm 4c.jpg|thumb|eft ventricular aneurysm: thinned wall bottom right of picture (long axis view)]] | |||
*Thin or fibrotic ventricular wall | |||
**Muscle may be absent or necrotic | |||
**Akinetic or dyskinetic wall (paradoxical ballooning) | |||
===Causes=== | ===Causes=== | ||
*Majority | *Majority | ||
*Rare | **Healed transmural [[MI]] (anterior or inferior most common) | ||
*Rare | |||
**[[HOCM]] | |||
**[[Chagas]] | |||
==Clinical Features== | ==Clinical Features== | ||
* | *May be asymptomatic | ||
*History of | *History of [[myocardial infarction]] | ||
*Angina | *[[Angina]] | ||
*Mitral | *[[Shortness of breath]] or dyspnea on exertion | ||
*[[CHF]] symptoms | |||
*Mitral regurgitation [[murmur]] | |||
*S3/S4 heart sounds | |||
*More common in women than men | |||
===Complications=== | |||
*[[Heart failure]] (LV aneurysm steals cardiac output) | |||
*[[Angina]] (increased O2 demand) | |||
*[[Ventricular dysrhythmias]] (LV stretch/scarring) | |||
*LV thrombus (50% of time), arterial embolism (stroke) | |||
*[[cardiac rupture|LV rupture]] (rarely occurs in mature LVA because of dense fibrosis) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{ST elevation DDX}} | |||
==Evaluation== | ==Evaluation== | ||
*[[CXR]] | ===Workup=== | ||
*TTE | [[File:LeftvAneurysmCrop.jpg|thumb|ECG of left ventricular aneurysm. Note the ST elevation in the anterior leads.]] | ||
*[[ECG]] | |||
**Persistent characteristic ST elevation after MI | |||
**Non-specific ST segment changes | |||
**Q or QS waves | |||
**T waves small relative to QRS | |||
**No reciprocal changes | |||
*[[CXR]] | |||
**Prominent left heart border | |||
**Calcified aneurysm | |||
**May have mass-like appearance | |||
*[[echocardiography|TTE]] | |||
*LV angiography | |||
*Cardiac MRI | |||
===Diagnosis=== | |||
''Differentiate left ventricular aneurysm from [[STEMI]] and other causes of [[ST-elevation]]'' | |||
*Strongly suspect [[STEMI]] if: | *Strongly suspect [[STEMI]] if: | ||
**Symptomatic | **Symptomatic | ||
**No [[q waves]] present (LV aneurysm typically produces significant q waves) | **No [[q waves]] present (LV aneurysm typically produces significant q waves) | ||
**Evolving changes on serial | **Evolving changes on serial ECG | ||
**Reciprocal changes | **Reciprocal changes | ||
*Consider two rules to differentiate<ref>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.</ref> | *Consider two rules to differentiate<ref>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.</ref> | ||
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***If any lead in V1-V4 has T-wave amplitude to QRS amplitude ratio > 0.35 | ***If any lead in V1-V4 has T-wave amplitude to QRS amplitude ratio > 0.35 | ||
***Suggestive of STEMI, with ~89% accuracy | ***Suggestive of STEMI, with ~89% accuracy | ||
{{STEMI Stages of Development}} | |||
==Management== | ==Management== | ||
*Be sure to rule out acute or subacute | *Be sure to rule out acute or subacute coronary syndrome | ||
===Medical Therapy (first line)=== | ===Medical Therapy (first line)=== | ||
*Afterload reduction (ACEI) | *Afterload reduction ([[ACEI]]) | ||
*Antianginal (Nitro) | *Antianginal ([[Nitro]]) | ||
*Anticoagulation (if LV thrombus) | *[[Anticoagulation]] (if LV thrombus) | ||
===Surgical Therapy=== | ===Surgical Therapy=== | ||
*Aneurysmectomy and CABG (and possible valve repair) if ventricular arrhythmias and/or HF refractory to medical therapy | *Aneurysmectomy and CABG (and possible valve repair) if ventricular arrhythmias and/or HF refractory to medical therapy | ||
== | ==Disposition== | ||
* | *Cardiothoracic surgery consultation | ||
==See Also== | ==See Also== | ||
[[ | *[[Myocardial Infarction Complications]] | ||
[[ | *[[Left ventricular pseudoaneurysm]] | ||
==References== | |||
<references/> | <references/> | ||
[[Category:Cardiology]] | |||
Latest revision as of 15:32, 25 September 2019
Background
- Thin or fibrotic ventricular wall
- Muscle may be absent or necrotic
- Akinetic or dyskinetic wall (paradoxical ballooning)
Causes
Clinical Features
- May be asymptomatic
- History of myocardial infarction
- Angina
- Shortness of breath or dyspnea on exertion
- CHF symptoms
- Mitral regurgitation murmur
- S3/S4 heart sounds
- More common in women than men
Complications
- Heart failure (LV aneurysm steals cardiac output)
- Angina (increased O2 demand)
- Ventricular dysrhythmias (LV stretch/scarring)
- LV thrombus (50% of time), arterial embolism (stroke)
- LV rupture (rarely occurs in mature LVA because of dense fibrosis)
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Evaluation
Workup
- ECG
- Persistent characteristic ST elevation after MI
- Non-specific ST segment changes
- Q or QS waves
- T waves small relative to QRS
- No reciprocal changes
- CXR
- Prominent left heart border
- Calcified aneurysm
- May have mass-like appearance
- TTE
- LV angiography
- Cardiac MRI
Diagnosis
Differentiate left ventricular aneurysm from STEMI and other causes of ST-elevation
- 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
STEMI Stages of Development
| Stage | Duration | Timing | Finding | ECG |
| 1 |
|
30min - hours | Hyperacute T waves
|
Normalizes in days, weeks, or months |
| 2 |
|
Minutes - hours | ST segment elevation
|
ST segment resolution occurs over 72hrs; completely resolves within 2-3wks |
| 3 |
|
Within 1hr; completed within 8-12hr | Q waves | Persist indefinitely in 70% of cases |
Management
- Be sure to rule out acute or subacute 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
Disposition
- Cardiothoracic surgery consultation
See Also
References
- ↑ 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.