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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • True aneurysm:

    • – Echocardiographic evidence of thinned, scarred myocardium that deforms the diastolic silhouette of the left ventricle with systolic akinesis or dyskinesis

  • False aneurysm:

    • – Echocardiographic evidence of a thin-walled sac communicating with an infarcted segment of the left ventricle by a narrow neck

    • – Systolic expansion of the sac is often observed

    • – Color-flow imaging shows flow in and out of the sac

GENERAL CONSIDERATIONS

  • True left ventricular (LV) aneurysms develop in less than 5% of all patients with acute myocardial infarction (MI)

  • Intraventricular pressure stretches the infarcted noncontractile segment, leading to aneurysm formation

  • Over time, dense fibrous tissue replaces infarcted myocardium, but systolic expansion of the segment can be visualized on echocardiogram

  • Aneurysms are more likely to occur after an anterior MI, particularly at the apex

  • Rupture is rare, unlike in pseudoaneurysm

  • High incidence of ventricular arrhythmias is major cause of increased mortality

  • Calcification of the scar may occur eventually and may be visible on chest x-ray

  • Thrombus formation in the aneurysm is common

  • In pseudoaneurysm, the wall is made up of thrombus and pericardium, and the risk of rupture is high

  • LV aneurysm can occur in nonischemic heart diseases such as Chagas’ disease and hypertrophic cardiomyopathy

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea secondary to LV dysfunction

  • Chest pain may be present if there is associated pericarditis

PHYSICAL EXAM FINDINGS

  • Enlarged and sustained precordial impulse

  • Third or fourth heart sounds

DIFFERENTIAL DIAGNOSIS

  • Akinetic or dyskinetic segments without diastolic deformity

  • Pericardial cyst or loculated effusion

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, brain natriuretic peptide test, troponin

ELECTROCARDIOGRAPHY

  • ECG: persistent ST elevation with Q waves most common

IMAGING STUDIES

  • Echocardiogram shows:

    • – Systolic expansion of a thin-walled segment of the LV and often the presence of thrombus (laminated or fresh)

    • – The size of the neck of the aneurysm compared with the fundus of the LV is useful for distinguishing true aneurysm from pseudoaneurysm

    • – In pseudoaneurysm, the neck is small (< 50% of diameter of fundus)

  • Cardiac MRI can also be used to identify LV aneurysms and may be useful if echocardiography is not diagnostic

DIAGNOSTIC PROCEDURES

  • Left ventriculography can also demonstrate aneurysms and should be done if coronary angiography is done

TREATMENT

CARDIOLOGY REFERRAL

  • Heart failure

  • Ventricular arrhythmias

  • Persistent angina

  • Systemic emboli or visible thrombus

HOSPITALIZATION CRITERIA

  • Pulmonary edema

  • Unstable angina

  • Symptomatic ventricular arrhythmias

  • Stroke or peripheral arterial occlusion

MEDICATIONS

  • Heart failure medications as needed

  • Antiarrhythmic medications as ...

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