Ventricular Aneurysm (Left Ventricular Aneurysm)

What happens in a ventricular aneurysm

After a large heart attack, the affected heart muscle dies and is replaced by scar tissue over several weeks. If the damage went through the full thickness of the wall, the scar can stretch under the pressure of each heartbeat, forming a thin, bulging pouch. Instead of squeezing inward with the rest of the ventricle, the aneurysm bulges outward (called dyskinesia). This:

• Wastes part of each heartbeat, reducing pumping efficiency
• Creates an area of slow-moving blood where clots can form
• Leaves scar edges that can trigger dangerous electrical circuits

Most aneurysms involve the front wall and apex after a blocked left anterior descending artery. With fast reopening of blocked arteries (stents or clot-busting drugs), they are now much less common than in the past.

True vs false ventricular aneurysm

A pseudoaneurysm is a form of cardiac rupture and is an emergency.

Causes

• Heart attack: by far the most common cause, especially a large, untreated or late-treated heart attack
• Hypertrophic cardiomyopathy: some patients with mid-ventricle narrowing develop an apical aneurysm, which raises the risk of arrhythmias and clots
• Chagas disease: a parasitic infection common in Latin America that causes apical aneurysms
• Cardiac sarcoidosis, myocarditis and chest trauma
• Congenital ventricular aneurysms, rare

Symptoms

Small aneurysms may cause no symptoms. When symptoms occur, they come from the complications:

• Shortness of breath, fatigue and swelling from heart failure
• Palpitations, dizziness or fainting from ventricular tachycardia
• Chest pain (angina), often from the underlying coronary disease
• Stroke or limb ischemia from a clot that breaks off

Complications

• Heart failure: the most common problem, especially when the aneurysm is large.
• Ventricular arrhythmias: ventricular tachycardia and ventricular fibrillation can cause sudden cardiac death.
• Left ventricular thrombus: clots form inside the aneurysm and can travel to the brain, causing stroke, or to the gut, kidneys or limbs.
• Rupture: rare with true aneurysms.

Diagnosis

• ECG: ST-segment elevation that persists weeks after a heart attack is a classic clue.
• Echocardiogram: shows the thin, bulging wall, overall pumping function (ejection fraction) and any clot. A contrast echo improves views.
• Cardiac MRI: the best test to measure the aneurysm, show scar and detect small clots.
• CT or angiography: to look at coronary arteries before procedures and distinguish true from false aneurysms.
• Heart rhythm monitoring if palpitations or fainting occur.

Treatment

Medicines

• Heart failure medicines that improve survival: ACE inhibitors, ARBs or sacubitril-valsartan, beta-blockers, mineralocorticoid receptor antagonists and SGLT2 inhibitors
• Anticoagulants (blood thinners) when a clot is seen, usually for at least 3 to 6 months with repeat imaging, and sometimes long-term
• Antiplatelet medicines, statins and risk factor control for coronary disease
• Antiarrhythmic medicines for recurrent ventricular tachycardia

Devices and procedures

• Implantable cardioverter-defibrillator (ICD): for people at high risk of sudden death, such as those with low ejection fraction or ventricular tachycardia
• Catheter ablation: to destroy the electrical circuits around the scar that cause ventricular tachycardia
• Coronary revascularization: stents or bypass surgery for ongoing blocked arteries

Surgery

Aneurysmectomy or surgical ventricular reconstruction removes or excludes the scarred area and restores a more normal ventricle shape, usually combined with bypass surgery. It is considered for:

• Heart failure or angina that persists despite medicines
• Ventricular arrhythmias that do not respond to other treatment
• Repeated clots despite anticoagulation
• A false aneurysm (pseudoaneurysm)

Outlook

Outlook depends on the size of the aneurysm, overall heart function and the extent of coronary disease. People with small aneurysms and good pumping function often do well on medicines. Large aneurysms with heart failure carry higher risk. Modern heart failure treatment, ICDs and early reperfusion after heart attacks have improved survival.

Frequently asked questions

What causes a left ventricular aneurysm?

Most are caused by a large heart attack that destroyed a full-thickness area of heart muscle, often in the front wall and tip of the heart. The scar thins and bulges over the following weeks. Less common causes include hypertrophic cardiomyopathy, Chagas disease, sarcoidosis, myocarditis and chest injury.

Is a ventricular aneurysm dangerous?

It can be, mainly because of heart failure, dangerous heart rhythms and clots that can cause stroke. True aneurysms rarely burst, but false aneurysms (pseudoaneurysms) are at high risk of rupture and need urgent surgery. With treatment and monitoring, many people live for years with a stable aneurysm.

Can you live a normal life with a left ventricular aneurysm?

Many people can, especially if the aneurysm is small and heart function is reasonable. Taking heart failure medicines, blood thinners if prescribed, staying active within cardiac rehab guidance, and attending follow-up imaging help. Symptoms such as breathlessness or palpitations should be reported promptly.

What is the difference between a ventricular aneurysm and a pseudoaneurysm?

A true ventricular aneurysm is a bulge of scarred but intact heart wall with a wide neck and low rupture risk. A pseudoaneurysm is a contained tear through the heart wall, held in by the pericardium or clot, usually with a narrow neck. It is much more likely to rupture and typically needs surgery.

How is a ventricular aneurysm treated?

Most are treated with heart failure medicines, blood thinners if a clot forms, and treatment of coronary disease. An ICD or catheter ablation may be used for dangerous rhythms. Surgery to remove or reshape the aneurysm is reserved for persistent heart failure, arrhythmias, recurrent clots or false aneurysms.