Definition

  Left ventricular aneurysm (LVA): Balloon-like bulging of a part of LV myocardium which

      does not contract throughout the cardiac cycle.

 
Dyskinesis : A part of LV myocardium which contracts during diastole and relaxes during systole

      (paradoxical movement).

  Myocardial infarction is the most common cause of ventricular aneurysm and dyskinesia.




Clinical significance of an LVA

  Since aneurysm is a non-contracting part of the ventricle, it does not contribute to the cardiac output.

      The non-contracting aneurysm even steals some of the cardiac output produced by the contracting

      myocardia segments.

      Therefore, aneurysms are usually associated with heart failure.

  Aneurysms are associated with cardiac arrhythmias.

  Aneurysms may contain thrombus which may result in systemic embolization.




ECG abnormalities described in patients with LVA

1. Persistent ST segment elevation

2.
Fragmented QRS complex

3.
Prominent R wave in lead aVR (Goldberger sign)

  The presence of above ECG findings are not pathognomonic for the presence of LVA.

  Their presence may only suggest the presence of an LVA.

  Absence of the above ECG abnormalities does not exclude the presence of LVA.




Persistent ST segment elevation

  The well-known ECG sign of LVA is persistent (more than 2 weeks) ST segment elevation.

  The ST segment elevation usually has a
rounded (domed) appearance.

  Generally Q waves and negative T waves accompany the ST segment elevation.

  Unlike acute ischemia, the ST segment elevation of LVA is persistent.

  Unlike acute ischemia, reciprocal ST segment depression in other leads does not coexist.

  However, the sensitivity and specificity of ST elevation in the diagnosis of LVA are poor.

      It has been reported that only 10% of the patients in the post-infarction setting with LVA

      exhibit a higher than 0.1 mV ST-segment elevation.

  Persistent ST segment elevation is not specific to LVA.

      It may be seen in patients with LV dyskinesia, too.




Fragmented QRS complex

  The presence in coronary patients with narrow QR or fractioned QRS morphologies

      (
rSR' pattern or its variants), especially in II and V3-V6,

      has been considered a marker of LVA.

  The specificity of these findings for LVA in patients with ischemic heart disease

      is very high (>90%), although its sensitivity is much lower (50%).

  Right ventricular aneurysms may be seen in patients with arrhythmogenic right ventricular

      cardiomyopathy/dysplasia.

  It has been reported that fragmented QRS complex predicts the arrhythmic events in patients with

      arrhythmogenic right ventricular cardiomyopathy/dysplasia.




What happens to ST segment elevation after aneurysmectomy?

  It has been reported that, after aneurysmectomy ST segment elevation

                  - remains unchanged in 61%

                  - improves in 26%

                  - becomes more pronunced in 13%

  It has been suggested that the ST segment elevation does not originate in the injured myocardium

      adjacent to the LVA.




References

  Eur Heart J 1994;15:1500-1504.

  Am Heart J,1965;70:753-760.

  Ann Noninvasive Electrocardiol 2006;11:132-138.

  Brit Heart J 1969;31:357-364.

  Brit Heart J 1970;32:440-448.

  J Cardiovasc Electrophysiol 2013;24:1260-1266.

  World J Cardiol 2014 April 26; 6(4): 154-174.

  Am J Cardiol 1984;53:1542-1546.

  J Electrocardiol 1984;17:75-77.





ECG 1. The ECG above is from an 89 years-old man who had experienced acute anterior myocardial infarction twice.
ECHOcardiography showed a very depressed left ventricle with an ejection fraction of about 15%, apical aneurysm and
mural thrombus. Anterior leads show Q waves and domed ST segment elevation.
Leads V4 to V6 also show negative T waves.
Lead aVR shows prominent R waves (Goldberger sign).
Leads II and III also show interatrial block.

Click here for a more detailed ECG





ECG 2. The compact ECG above belongs to a 44 years-old man with old inferior myocardial infarction.
His RCA and LAD arteries were stented at the time of the acute infarction.
Later, ECHOcardiography showed a large inferior LVA.
Leads II, III and aVF show Q waves, minimal ST elevation, negative T waves and fragmented QRS.





ECG 3. The ECG above belongs to a 41 years-old man with old anterior wall myocardial infarction.
Leads V3 and V4 show fragmented QRS. No typical ST segment elevation is seen.
ECHOcardiography showed apical LVA in this patient.
Absence of typical ECG findings do not exclude the possibility of a LVA.

Click here for a more detailed ECG





ECG 4.The compact ECG above belongs to a 66 years-old man with old anterior myocardial infarction.
ECHOcardiography showed apical LVA.
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. The ECG above belongs to a 75 years-old woman who had experienced acute anterior myocardial infarction 8 years ago.
ECHOcardiography showed apical aneurysm.
Precordial leads show Q waves and ST segment elevation.
Fragmented QRS complexes, Goldberger sign and negative T waves are not seen in the above ECG.

Click here for a more detailed ECG





ECG 6. The ECG above belongs to a 59 years-old man who had experienced anterior wall myocardial infarction 7 years ago.
A recent ECHOcardiography examination showed aneurysm of the left ventricular apex and anterior septum.
Only the septal leads (V1 and V2) show ST segment elevation. Leads V2 to V6 show negative T waves.

Click here for a more detailed ECG





ECG 7. The ECG above belongs to a 49 years-old man with old anterior wall myocardial infarction.
Precordial leads show Q waves, ST elevation and negative T waves.
ECHOcardiography showed a large apical LVA.
Left ventricular systolic dysfunction was depressed and the ejection fraction was about 30%.

Click here for a more detailed ECG





ECG 8. The compact ECG above belongs to a 59 years-old man with old inferior wall myocardial infarction.
ECHOcardiography showed inferior LVA with an Ejection Fraction of about 38%.
Leads II, III and aVF show
domed ST segment elevation, Q waves and fragmented QRS complexes.





ECG 9a. The ECG above belongs to a 71 years-old man who had experienced acute anterior myocardial infarction 8 years ago.
He has 3-vessel (extensive) coronary artery disease, including the left main coronary artery.
His initial clinical diagnosis was acute inferior myocardial infarction with minimal elevation of the cardiac enzymes.
The above ECG was recorded before the coronary artery bypass graft operation.
Leads II, III and aVF show Q waves, minimal
ST elevation and negative T waves.
These leads also show fragmented QRS. ,
These findings may suggest the presence of LVA at first. However, ECHOcardiography did NOT show LVA in this patient.
Persistent (more than 2 weeks) and domed ST segment elevation is necessary for the ECG diagnosis of LVA.

Click here for a more detailed ECG




ECG 9b. The ECG above belongs to the same man. It was recorded 3 monhs after the coronary artery bypass graft operation.
A repeat ECHOcardiography examination did NOT show LVA.
Now, inferior leads show smaller q waves and upright T waves.
Only minimal ST segment elevation persists, but it is not domed.
This case shows that the sensitivity and specificity of ECG is not 100% in the diagnosis of LVA.

Click here for a more detailed ECG




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