Left Ventricular Aneurysm

Left ventricular aneurysm is a discrete, thinned, dyskinetic or akinetic region of the left ventricular wall composed of fibrous scar, usually following transmural infarction.

True aneurysm has a wide neck and contains myocardium and scar. Pseudoaneurysm is a contained rupture with a narrow neck.

Most arise in the anteroapical region after LAD occlusion, in 5 to 20% of anterior infarcts in the pre reperfusion era, now under 5%.

Contributing factors: delayed or absent reperfusion, large infarct, no collaterals, microvascular obstruction.

Complications: heart failure, ventricular tachycardia, mural thrombus with embolism, persistent ST elevation, angina, and rarely rupture (pseudoaneurysm).

• Heart failure symptoms, exertional dyspnoea, angina.
• Ventricular arrhythmias, palpitations, syncope.
• Systemic embolism (stroke, limb ischaemia).
• Displaced, dyskinetic apical impulse, paradoxical precordial bulge, third or fourth heart sound, systolic murmur of mitral regurgitation.
• Asymptomatic persistent ST elevation more than 4 to 6 weeks after infarction.

• ECG: persistent ST elevation with Q waves in anterior leads.
• Chest radiograph: bulge on left heart border, calcification.
• Echocardiography: thin, scarred, dyskinetic segment with wide neck (neck to maximal cavity diameter ratio over 0.5 in true aneurysm). Contrast echo detects thrombus.
• Cardiac MRI is the reference standard for anatomy, scar (late gadolinium enhancement) and thrombus.
• Pseudoaneurysm clues: narrow neck (ratio under 0.5), abrupt myocardial discontinuity, to and fro flow.
• Coronary angiography for revascularisation planning. Electrophysiology study for VT.

Medical

• Heart failure therapy: ACE inhibitor or sacubitril/valsartan, beta blocker (carvedilol 3.125 to 25 mg twice daily), spironolactone 25 to 50 mg, SGLT2 inhibitor, loop diuretics.
• Antiplatelets and statins for coronary disease.
• Anticoagulation (warfarin INR 2 to 3 or a DOAC) for 3 to 6 months when thrombus is present, repeat imaging before stopping. Routine long term anticoagulation is not indicated without thrombus or other indication.
• ICD for ejection fraction 35% or less, or sustained VT. Amiodarone 200 mg daily or catheter ablation for recurrent VT.

Surgical

• Indications: refractory heart failure or angina, recurrent VT unresponsive to therapy, recurrent embolism despite anticoagulation, with a viable remnant.
• Techniques: endoventricular circular patch plasty (Dor procedure) or linear repair, with concomitant coronary bypass and mitral surgery. Operative mortality 5 to 10%.
• Pseudoaneurysm warrants prompt surgical repair because of rupture risk.
• Transplantation or ventricular assist device for end stage failure.