Left ventricular aneurysm

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


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

Clinical Features

  • Can be asymptomatic
  • History of myocardial infarction
  • Angina, shortness of breath/dyspnea on exertion, CHF symptoms
  • Mitral regurgitation murmur, S3/S4
  • female>male

Differential Diagnosis

ST Elevation


  • 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


  • 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



  • 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


  1. 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.