Ultrasound of the Month: LV Aneurysm

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The Case

Initial Presentation

patient was noted to have ST elevation in I, aVL, and V2-V6 with associated Q-wave

The patient was noted to have ST elevation in I, aVL, and V2-V6 with associated Q-waves

An elderly woman without significant past medical history and with infrequent medical care presents to the emergency department (ED) for approximately three weeks of left-sided non-radiating chest pressure. The pain is worse with activities such as basic house chores. The pain was initially intermittent but became constant, prompting her visit to the ED. She denied shortness of breath, nausea, or diaphoresis.

Vitals: T 97.8 °F, HR 106, BP 87/52, RR 20, SpO2 97 % on room air

Exam: notable for tachycardia, clear lungs, no edema, no JVD

Hospital Course

The patient was taken to the cath lab as a STEMI activation where she was found to have 100 % LAD occlusion and had two drug-eluting stents placed. She was discharged home on goal-directed medical therapy. Cardiology performed echocardiography noted a left ventricular (LV) aneurysm with associated thrombus, an EF of 20-25 %, and diffuse dyskinesis of the septum, apex, and lateral myocardium. She was started on oral anticoagulation with warfarin for her LV aneurysm.

Subsequent Presentations at 4 and 6 weeks

The patient had two return visits to the ED for heart failure exacerbations with chest pain, shortness of breath, and paroxysmal nocturnal dyspnea. Bedside echocardiography was performed, with images below:

Parasternal Long Axis (PLAX) view obtained at 4 weeks

Apical 4 Axis (A4C) view obtained at 4 weeks

Parasternal Short Axis (PSAX) view obtained at 6 weeks

Subcostal View view obtained at 6 weeks. Images by: PGY-3 Joshua Ferreri, MD; PGY-3 Tony Fabiano, MD; PGY-3 Melanie Yates, MD

Final Presentation at 8 weeks

The patient returned with one week of worsening exertional dyspnea, paroxysmal nocturnal dyspnea with several night-time awakenings, and increased leg swelling. She had been adherent to all her prescribed medications but was not yet on a diuretic. She had no chest pain, nausea, diaphoresis, or any other concerning symptoms.

Vitals: Temp 97.3 °F, HR 110, BP 111/76, MAP 87, RR 18, SpO2 99 % on RA

ECG: Q-waves seen throughout the precordial leads as well as borderline ST elevations which were stable compared to prior. Troponin was 19 with a repeat stable at 18. BNP was 581. Chest X-ray was concerning for pulmonary edema.

ED Course: the patient was given nitroglycerin with symptomatic improvement as well as IV furosemide for presumed heart failure exacerbation and was admitted to the cardiology service.

Left Ventricular Aneurysm

Pathophysiology

A ventricular aneurysm is generally defined as a scarred, fibrotic outpouching of the ventricular wall lacking functional cardiac muscle which balloons outward during the cardiac cycle, frequently in systole (1). Aneurysms most commonly result from a transmural myocardial infarction leading to necrosis and remodeling of native tissue, although they have also been seen infrequently in the setting of blunt cardiac injury, sarcoidosis, infection, or congenital malformation. They can be seen as early as 48 hours after an infarction and typically present within two weeks. The majority, up to 80 %, of LVA’s are located apically or anteriorly resulting from occlusion of the left anterior descending coronary artery. A smaller proportion, 15 %, develop on the inferior wall due to occlusion of the right coronary artery. Ventricular aneurysms develop in 3-15 % of patients following myocardial infarction (2). Dyskinesis in the ventricular aneurysm can lead to clot formation in approximately 50 % of cases. Congestive heart failure may develop from both loss of compliance leading to diastolic dysfunction as well as loss of functional myocardium leading to systolic dysfunction (3).

Clinical Presentation

Patients with ventricular aneurysms most commonly present with symptoms suggestive of congestive heart failure such as dyspnea, chest pain, and peripheral edema. Examination may be notable for a laterally displaced point of maximal impulse. Auscultation may reveal an S3 gallop or systolic murmur. Chest X-ray may demonstrate cardiac silhouette enlargement although it will typically not show an aneurysm unless the aneurysm has developed calcifications (4).

Diagnosis

Echocardiography is the initial imaging modality pursued with concern for ventricular aneurysm. LV aneurysms can be characterized through parasternal long-axis, parasternal short-axis, and apical four or two chamber views. They will typically have a large neck connecting a thin (<5 mm) segment of the ventricular wall which will paradoxically balloon outward during systole and demonstrate akinetic or dyskinetic motion. Echocardiography has demonstrated a sensitivity of 93% and specificity of 94% compared to ventriculography, which is the gold-standard for diagnosis of LV aneurysm (7, 8). LV pseudoaneurysm is another rare but known complication that can occur after mitral valve surgery or myocardial infarction. This occurs when there is a ventricular free wall rupture which has limited expansion and becomes constrained by the pericardium. Like true aneurysms, pseudoaneurysms demonstrate systolic expansion, however, in pseudoaneurysms this typically occurs through a narrow aneurysmal neck which demonstrates rapid flow in both systole and diastole. Both aneurysms and pseudoaneurysms have a high propensity to develop thrombus which is seen on echocardiography as a defined hyperechoic echotexture (9).

Natural History/Complications

There is wide variation in prognosis for patients with LV aneurysms’s with survival rates ranging from 12 % at 5 years to 72 % at 4 years. Complications of LV aneurysm include ventricular arrhythmias, thromboembolic disease, angina, and both systolic and diastolic heart failure. Although the presence of LV aneurysm in the setting of heart failure is associated with increased mortality compared to those with heart failure but without an LV aneurysm, it has not been found to be an independent predictor of mortality. Rather, age, systolic function, and extent or coronary artery disease have been found to be independently correlated with decreased survival and these predictors tend to be worse in individuals with an LV aneurysm (10).

Management

Moderate-sized or smaller ventricular aneurysms can be treated medically, with a five-year survival rate approaching 90 %. Medical management follows that of heart failure, with afterload reduction, anti-anginal medication, and consideration of anticoagulation given the risk of thrombus formation. Surgical repair, aneurysmectomy, has a growing number of indications due to decreased operative mortality and improving operative techniques. Indications include intractable arrhythmias, heart failure that is unresponsive to medical therapy, refractory angina, and those with embolic disease unable to take oral anticoagulation therapy (12,13).

Case Resolution

The patient was admitted to the cardiology service for GDMT titration and initiation of diuretics. During her hospital course she was found to have intermittent complete heart block and underwent AICD placement. She was continued on oral anticoagulation with warfarin.

AUTHORED BY JEREMY SOBOCINSKI, MD

Dr. Sobocinski (@jsobocin) is a PGY-2 in Emergency Medicine at the University of Cincinnati

PEER REVIEW BY PATRICK MINGES, MD

Dr. Minges (@mingespg) is an Ultrasound-trained and Clinical Faculty in Emergency Medicine at the University of Cincinnati.

EDITING AND LAYOUT BY MARTINA DIAZ, MD

Dr. Diaz (@martina_diazb) is a PGY-3 in Emergency Medicine at the University of Cincinnati and the current Resident Editor of Ultrasound of the Month.

References

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2. Fong FF, Vaitenas I, Malaisrie C, Magainti K. Mechanical Complications of Acute Myocardial Infarction. JAMA Cardiology. 2020 Dec;6(3)341-349. Doi10.1001/jamacardio.2020.3690.

3. Friedman BM, Dunn MI. Postinfarction ventricular aneurysms. Clin Cardiol. 1995 Sep;18(9):505-11. doi: 10.1002/clc.4960180905. PMID: 7489606.

4. Frances C, Romero A, Grady D. Left Ventricular Pseudoaneurysm. J AM Coll Cardiol. 1998. Sept;32(3):557-561.

5. Matsumo M, et al. Left ventricular aneurysm and the prediction of left ventricular enlargement studied by two-dimensional echocardiography: quantitative assessment of aneurysm size in relation to clinical course. Circulation. 1985. Aug;72(2):280-86.

6. Jahnke C, et al. Three-dimensional echocardiography for quantitative analysis of left ventricular aneurysm. Echocardiography. 2010. Jan;27:64-8. DOI: 10.1111/j.1540-8175.2009.00972.

7. Faxon D, et al. Prognostic Significance of Angiographically Documented Left Ventricular Aneurysm from the Coronary Artery Surgery Study (CASS). American Journal of Cardiology. 1982. Jul;50:157-164.

8. Visser CA, Kan G, David GK, Lie KI, Durrer D. Echocardiographic-cineangiographic correlation in detecting left ventricular aneurysm: a prospective study of 422 patients. Am J Cardiol. 1982 Aug;50(2):337-41. doi: 10.1016/0002-9149(82)90185-0. PMID: 7102561.

9. Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL. Two-dimensional echocardiographic recognition of left ventircular pseudoaneurysm. Circulation. 1980 Jan;62(3):294-303.

10. Mourdjinis A, Olsen E, Raphael MJ, Mounsey JP. Clinical diagnosis and prognosis of ventricular aneurysm. Br Heart J. 1968 Jul;30(4):497-513. doi: 10.1136/hrt.30.4.497. PMID: 5659397; PMCID: PMC487659.

11. Antunes MJ, Antunes PE. Left-ventricular aneurysms: from disease to repair. Expert Rev Cardiovasc Ther. 2005 Mar;3(2):285-94. doi: 10.1586/14779072.3.2.285. PMID: 15853602.

12. Rao G, Zikria EA, Miller WH, Samadani SR, Ford WB. Experience with sixty consecutive ventricular aneurysm resections. Circulation. 1974 Aug;50(2 Suppl):II149-53. PMID: 4843618.

13. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119-177. doi: 10.1093/eurheartj/ehx393. PMID: 28886621.