Is a ventricular aneurysm typically congenital?

Ventricular Aneurysms: Congenital or Acquired?

Ventricular aneurysms are typically acquired conditions, most commonly occurring as a complication of transmural myocardial infarction, rather than being congenital in origin. 1

Etiology of Ventricular Aneurysms

Primary Causes:

• Acquired (Most Common):

  • Myocardial infarction: The vast majority of ventricular aneurysms (particularly left ventricular aneurysms) develop as a consequence of transmural myocardial infarction 2
  • Pathogenesis: Infarct expansion early after acute myocardial infarction, generally related to infarct size 2
  • Risk factors that may promote aneurysm formation include:
    • Underlying hypertension
    • Use of steroids
    • Use of nonsteroidal anti-inflammatory agents 2

• Congenital (Rare):

  • While ventricular aneurysms are predominantly acquired, they can rarely be associated with congenital heart disease
  • Anomalous coronary artery conditions may predispose to myocardial ischemia and subsequent aneurysm formation 3
  • Certain genetic disorders may contribute to aneurysm formation, as seen in a case report of a patient with mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome) who developed a left ventricular aneurysm 4

Characteristics of Ventricular Aneurysms

• Definition: Circumscribed, thin-walled fibrous, noncontractile outpouchings of the ventricle 2
• Location: Majority are apically located true aneurysms of the left ventricle 2
• Structure: True aneurysms include all cardiac layers, usually with a large segment involved 1

Clinical Sequelae

Ventricular aneurysms can lead to several complications:

• Congestive heart failure
• Thromboembolism
• Angina pectoris
• Ventricular tachyarrhythmias 2
• Reduced ventricular stroke volume
• Mitral regurgitation 1

Diagnosis

Multimodality imaging is essential for comprehensive assessment of ventricular aneurysms:

• Echocardiography (transthoracic and transesophageal)
• Cardiac MRI
• CT angiography
• Cardiac catheterization (with the advantage of delineating coronary anatomy) 2, 1

Management

Treatment approaches include:

1. Medical management:

   • Heart failure therapy (ACE inhibitors, diuretics, digoxin)
   • Anticoagulation with warfarin (typically for at least 3 months after acute MI)
   • Antiarrhythmic treatment guided by electrophysiologic studies 2, 1

2. Surgical intervention:

   • Remains the gold standard when indicated
   • Ventricular aneurysmectomy can relieve persistent cardiac failure and angina
   • May reduce the risk of systemic embolism 1, 5

3. Device therapy:

   • Implantable cardiac defibrillator may be indicated to reduce the risk of fatal arrhythmias 1

Important Distinctions

• True aneurysm vs. Pseudoaneurysm (False aneurysm):
  • True aneurysms involve all layers of the heart wall
  • Pseudoaneurysms occur when the pericardium forms the aneurysm wall, with particular risk of late rupture 2

Conclusion

While ventricular aneurysms can rarely be associated with congenital heart conditions, they are predominantly acquired pathologies, most commonly resulting from myocardial infarction. The distinction is important for proper management and prognostication.