Left ventricular aneurysm

Background

Left ventricular aneurysm: thinned wall in upper right of picture (short axis view)

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

• Majority
  • Healed transmural MI (anterior or inferior most common)
• Rare
  • HOCM
  • Chagas

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
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Evaluation

Workup

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
• 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
  • 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

STEMI Stages of Development

Stages of STEMI development

Stage	Duration	Timing	Finding	ECG
1		30min - hours	Hyperacute T waves >6mm limb leads >10mm precordial leads	Normalizes in days, weeks, or months
2		Minutes - hours	ST segment elevation 0.1mV in two or more contiguous leads	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

• Myocardial Infarction Complications
• Left ventricular pseudoaneurysm