Left ventricular aneurysm: Difference between revisions
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
* | *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== | ||
Revision as of 17:02, 17 March 2019
Background
- Thin or fibrotic ventricular wall
- Muscle may be absent or necrotic
- Akinetic or dyskinetic wall (paradoxical ballooning)
Causes
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
- 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
- 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
Disposition
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
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.