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Ventricular Aneurysm

A ventricular aneurysm develops either as a congenital or acquired malformation, but it is most frequently described as a complication of acute myocardial infarction. The clinical presentation can be asymptomatic, while chest pain, dyspnea, bradycardia, and a pericardial friction rub are some of the observed symptoms. A thorough clinical assessment with electrocardiography (ECG) can raise sufficient evidence to employ imaging studies (ventriculography, echocardiography, or magnetic resonance imaging). The latter is the cornerstone for determining the type (true vs pseudoaneurysm) and its size.


Presentation

Signs and symptoms of a ventricular aneurysm are closely related to the clinical presentation of an acute myocardial infarction (AMI) [1] [2]. In fact, up to 95% of all ventricular aneurysms are thought to occur in this patient population [3]. Other etiologies associated with this cardiac pathology are trauma, surgical interventions involving the heart, and infections, whereas their appearance as isolated congenital lesions has also been noted [3] [4] [5] [6] [7]. Despite the different types of aneurysms based on the degree of rupture (a true aneurysm involves the full thickness of the myocardium, while pseudoaneurysms are contained by the pericardial sac), patients present in a similar fashion [1] [2]. Interestingly, a large number of patients are asymptomatic and smaller aneurysms, in general, do not pose a significant risk to the patient [1] [2]. In approximately 60% of patients who are symptomatic, however, typical chest pain seen in MI may be reported, as well as dyspnea and hypotension accompanied by bradycardia [2] [6]. A pericardial friction rub is also observed, together with heart murmurs and an overall decrease in the intensity of heart sounds [2]. Unfortunately, symptomatic patients usually progress to heart failure and are at risk for aneurysmal rupture (which can be life-threatening), development of arrhythmias and insufficiency of the coronary arteries, thrombosis, bacterial endocarditis, and even death [6]. For this reason, an early diagnosis is crucial.

Congestive Heart Failure
  • Complications of ventricular aneurysm such as chronic congestive heart failure and rupture of the aneurysm were infrequent causes of death, and systemic embolic phenomena were not observed as a cause of death.[ahajournals.org]
  • heart failure Arrhythmias Peripheral embolization Usually are either true or false aneurysms True ventricular aneurysms Localized outpouching of ventricular cavity Associated with dyskinesia Wide-mouthed in connection with the LV Anterolateral or apical[learningradiology.com]
  • Post-infarction LV-remodelling can be characterised by chamber dilatation and abnormal shape leading to systolic and diastolic dysfunction and, in the advanced form, to congestive heart failure.[cardiothoracicsurgery.org]
Coronary Artery Disease
  • artery disease and myocardial infarction.[accesssurgery.mhmedical.com]
  • The patient was known to suffer from Coronary Artery Disease and experienced a myocardial infarction (MI) 10 years back where a coronary artery bypass surgery (CABG) was performed.[omjournal.org]
  • The extent of coronary artery disease and collateral blood supply in Groups I and II were directly related (p 0.012). Neither age, sex nor risk factors for coronary disease correlated with aneurysm formation.[content.onlinejacc.org]
  • Coronary angiography excluded coronary artery disease, and local or systemic inflammation was excluded based on laboratory data and MRI. MRI also excluded other cardiomyopathies.[jstage.jst.go.jp]
  • The aim of surgical therapy is restoration of LV geometry, LV volume reduction, and the relief of ischaemia by CABG in the presence of concomitant coronary artery disease in viable myocardial territory (4).[ctsnet.org]
Asymptomatic
  • In this article, we describe a double-chambered left ventricle (LV) associated with a functional right ventricular (RV) aneurysm and right atrial (RA) enlargement in an asymptomatic 24-year-old woman with a family history of sudden cardiac death.[ncbi.nlm.nih.gov]
  • Interestingly, a large number of patients are asymptomatic and smaller aneurysms, in general, do not pose a significant risk to the patient.[symptoma.com]
  • During a six-month follow-up, the patient was asymptomatic, with no cystic appearance on transthoracic echocardiography.[ncbi.nlm.nih.gov]
  • Cardiovascular surgery therapy is not indicated in asymptomatic DMD patients with LV aneurysm. Management of LV aneurysm in this disease relies mainly on medical therapy [ 3 ].[em-consulte.com]
  • Thus, the prognosis seems to be favorable, and most of the neonates are asymptomatic at birth 5.[scielo.br]
Tachycardia
  • Finally, after 9 days of persistent ventricular tachycardia, resection of the aneurysm was carried out with excellent eventual recovery and correction of ventricular tachycardia.[annals.org]
  • The patient's ventricular tachycardia (VT) was refractory to different treatments. Due to the presence of a ventricular thrombus, epicardial ablation was performed but the VT recurred.[ncbi.nlm.nih.gov]
  • On Holter ECG monitoring frequent PVC (26,333 beats/day; 24.7% of the total heart rate) and non-sustained ventricular tachycardia (NSVT) were noted ( Figure 1B ).[jstage.jst.go.jp]
  • Tachycardia is another finding. Cardiovascular Common findings in patients with LV aneurysm include: [1] Palpation Diffuse, sustained apical systolic thrust and a double impulse. Displaced apical impulse to the left of the mid clavicular line .[wikidoc.org]
  • CLINICAL CASE A 49-year-old woman without a family history of heart disease with a background of paroxysmal supraventricular tachycardias for 17 years.[revespcardiol.org]
Heart Disease
  • Pathogenesis of chronic Chagas heart disease. Circulation 2007;115:1109-23. 8. Bonney KM, Engman DM. Chagas heart disease pathogenesis: One mechanism or many? Curr Mol Med 2008;8:510-8. 9. Rossi MA.[heartviews.org]
  • Braunwald's heart disease : a textbook of cardiovascular medicine . Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455751341 .[wikidoc.org]
  • From how ‘broken heart syndrome’ can also be triggered by happy events, to how cardiologists are now using 3D printing to personalise treatment for heart disease.[eurheartj.oxfordjournals.org]
  • Left ventricular aneurysm, intraaneurysmal thrombus and systemic embolus in coronary heart disease. Chest 1980;77:586. [Pubmed] [8] ??Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction.[revistanefrologia.com]
  • disease Pericardial cyst Discussion Background Aneurysms of the left ventricle are a potential complication of myocardial infarction.[vcuthoracicimaging.com]
Pericardial Friction Rub
  • A pericardial friction rub is also observed, together with heart murmurs and an overall decrease in the intensity of heart sounds.[symptoma.com]
  • Pericardial friction rub or decreased heart sound, elevation of both left and right side, filling pressure, sinus bradycardia or junctional rhythm, are all signs of pseudo-aneurysm [ 4 ].[cardiothoracicsurgery.org]
Diminished Heart Sounds
  • A personal history that reveals MI or recent surgery of the heart may be a useful piece of information, whereas auscultation of the heart (during which murmurs, bradycardia, and/or diminished heart sounds are revealed) might reveal crucial findings to[symptoma.com]
Pansystolic Murmur
  • There may be an apical pansystolic murmur due to the LV wall anatomical distortion, and also from mitral regurgitation , if present. References Mann, Douglas (2015). Braunwald's heart disease : a textbook of cardiovascular medicine .[wikidoc.org]
Joint Stiffness
  • Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain[emedicine.medscape.com]
Contusion
  • The vast majority of LV aneurysms result from myocardial infarction although other etiologies are encountered, including blunt chest injury with myocardial contusion, Chagas disease, and cardiac sarcoidosis.[journals.lww.com]

Workup

Imaging studies are necessary to make the diagnosis of a ventricular aneurysm. Still, the physician plays a key role in raising clinical suspicion toward a cardiac origin of signs and symptoms. A detailed patient history should cover the onset of symptoms and their progression. A personal history that reveals MI or recent surgery of the heart may be a useful piece of information [1], whereas auscultation of the heart (during which murmurs, bradycardia, and/or diminished heart sounds are revealed) might reveal crucial findings to make the initial diagnosis. As soon as sufficient evidence is raised, electrocardiography should be performed, but because a distinction between a true aneurysm and a pseudoaneurysm can't be made during this procedure (the importance lies in the somewhat different prognosis and treatment), direct imaging of the heart is necessary [1]. Cardiac ultrasonography (echocardiography) is a useful and noninvasive first-line study that provides very fast results but its ability to visualize an entire aneurysm and determine the exact physical characteristics is inferior, compared to computed tomography (CT) or magnetic resonance imaging (MRI) [1] [2] [4] [8]. Contrast-enhanced MRI is even more superior, as it allows for a complete evaluation of the myocardium and, thus, is able to differentiate a true aneurysm from a pseudoaneurysm [1].

Inferior Q Wave
  • His clinical history was characterized by a silent inferior-basal myocardial infarction detected by a control ECG that presented inferior Q waves, and he had not previously presented symptoms.[cardiothoracicsurgery.org]
ST Elevation
  • The only way to be sure that the ECG changes present are from an LV aneurysm (not ST elevation from an acute MI) is to have the patient’s history of a prior MI and cardiac imaging to document the presence of an aneurysm.[healio.com]
  • Classic ECG findings are persistent ST elevation and deep Q waves in the same leads.[radiopaedia.org]
  • Normal Right Bundle Branch Block (figure 2) This is normal RBBB, with rSR’, slight ST depression in V2 and V3, and no ST elevation anywhere. A non-pathologic RBBB has an rSR’ in V1-V3 and no ST elevation anywhere on the ECG.[hqmeded-ecg.blogspot.com]
  • Leads V2 to V6 show domed ST elevation. Leads V3 to V6 also show negative T waves. Fragmented QRS complexes in leads V4 to V6 suggest the presence of LVA. ECG 5.[metealpaslan.com]

Treatment

  • Surgery is the definitive treatment. However, it is not currently available in the country and patients cannot afford treatment abroad.[ncbi.nlm.nih.gov]
  • It is unclear as to whether polyphenol-containing topical treatments have similar effects.[ncbi.nlm.nih.gov]
  • Some people live with this type of aneurysm for many years without any specific treatment. Treatment is limited to surgery (ventricular reduction) for this defect of the heart.[en.wikipedia.org]
  • While patients with MINOCA usually do not need coronary artery intervention treatments, the prognosis could be worsened if the condition is not appropriately managed.[ncbi.nlm.nih.gov]
  • […] and minimally invasive treatments.[bumc.bu.edu]

Prognosis

  • While patients with MINOCA usually do not need coronary artery intervention treatments, the prognosis could be worsened if the condition is not appropriately managed.[ncbi.nlm.nih.gov]
  • The etiology is unknown, and there is a variable prognosis in the current literature. Approximately 20 cases detected by prenatal ultrasonography have been reported, with 4 of these cases indicating the presence of pericardial fluid.[ucdavis.pure.elsevier.com]
  • As soon as sufficient evidence is raised, electrocardiography should be performed, but because a distinction between a true aneurysm and a pseudoaneurysm can't be made during this procedure (the importance lies in the somewhat different prognosis and[symptoma.com]
  • It is suggested that the hemodynamic significance of ventricular aneurysms is not ordinarily great, in view of the unaffected statistical prognosis in its presence.[ahajournals.org]
  • In our case, LVA/LV ratio was 1 throughout the pregnancy that suggested poor prognosis ( Figure 2a ). With the relative enlargement of aneurysm, we expected poor prognosis of this fetus.[nature.com]

Etiology

  • etiology; ventricular function, left/drug effects/physiology[ncbi.nlm.nih.gov]
  • Although it occurs as a consequence of a variety of conditions, congenital ventricular septal defect (VSD) as an etiology for the RVA has not been previously reported.[ncbi.nlm.nih.gov]
  • The etiology is unknown, and there is a variable prognosis in the current literature. Approximately 20 cases detected by prenatal ultrasonography have been reported, with 4 of these cases indicating the presence of pericardial fluid.[ucdavis.pure.elsevier.com]
  • Other etiologies associated with this cardiac pathology are trauma, surgical interventions involving the heart, and infections, whereas their appearance as isolated congenital lesions has also been noted.[symptoma.com]
  • DISCUSSION Congenital VA is a rare clinical entity (0.4% of 750 cardiac necropsies) 4 that is diagnosed once other more common etiologies have been ruled out.[revespcardiol.org]

Pathophysiology

  • […] of authors favor defining left ventricular aneurysm more loosely as any large area of left ventricular akinesia or dyskinesia that reduces left ventricular ejection fraction. 3–5 This broader definition has been justified by data suggesting that the pathophysiology[accesssurgery.mhmedical.com]
  • The underlying pathophysiological processes are little understood; however, it is hypothesized that they result from a localized weakening of the ventricular wall due to an interruption in the development during embryogenesis, infection, or ischemia 2,3[scielo.br]
  • Congenital left ventricular aneurysms and diverticula: definition, pathophysiology, clinical relevance and treatment . Cardiology 2006; 106 : 63–72. 3. Weichert J , Chiriac A , Axt-Fliedner R .[nature.com]

Prevention

  • How can a ventricular aneurysm be prevented? Some aneurysms may be prevented if a heart attack is treated very soon after it starts. Developed by RelayHealth. Published by RelayHealth.[summitmedicalgroup.com]
  • The patient also received an implantable cardioverter-defibrillator for primary prevention.[doi.org]
  • Also ACE Inhibitors seem to prevent Left Ventricular remodeling and aneurysm formation.[en.wikipedia.org]
  • […] these complications, 7,8 although some groups defend a conservative attitude in asymptomatic patients and employ measures aimed at preventing endocarditis and embolism via oral antiplatelet or anticoagulation agents. 3 In our case, despite involving[revespcardiol.org]

References

Article

  1. Kumbasar B, Wu KC, Kamel IR, Lima JA, Bluemke DA. Left ventricular true aneurysm: diagnosis of myocardial viability shown on MR imaging. AJR Am J Roentgenol. 2002;179(2):472-474.
  2. Bisoyi S, Dash AK, Nayak D, Sahoo S, Mohapatra R. Left ventricular pseudoaneurysm versus aneurysm a diagnosis dilemma. Ann Card Anaesth. 2016;19(1):169-172.
  3. Alhasnawi M. Calcified Ventricular Aneurysm. Oman Med J. 2009;24(4):303-305.
  4. Giacobbe L, Williams P, Ramin K, Sivanandam S. Fetal Diagnosis of Left Ventricular Aneurysm: A Case Report. AJP Rep. 2011;1(2):91-94.
  5. Del Río M, Martínez J M, Bennasar M., et al. Prenatal diagnosis of a right ventricular diverticulum complicated by pericardial effusion in the first trimester. Ultrasound Obstet Gynecol. 2005;25:409–411.
  6. Ercan A, Senkaya I, Semizel E, Cil E. Left Ventricular Aneurysm in a 4-Year-Old Boy.Tex Heart Inst J. 2005;32(4):614-615.
  7. Gerlis LM, Partridge JB, Fiddler GI, Williams G, Scott O. Two chambered left ventricle: three new varieties. Br Heart J. 1981;46:278–284.
  8. Balakumar K. Prenatal diagnosis of left ventricular aneurysm. Indian J Radiol Imaging. 2009;19(1):84-86.

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Last updated: 2019-06-28 11:12