What is a Ventricular Aneurysm?
A ventricular aneurysm is a circumscribed, thin-walled, fibrous, non-contractile outpouching of the left ventricle that occurs as a consequence of transmural myocardial infarction, typically involving the apex. 1
The aneurysm develops when infarct expansion occurs early after acute MI, with occurrence generally relating to infarct size 1. The majority are true aneurysms (involving all cardiac layers) located at the LV apex, particularly following anterior wall infarctions 2, 1. The incidence has declined to <5% of STEMI patients due to timely reperfusion strategies 2.
Key Clinical Sequelae
The presence of a ventricular aneurysm leads to several important complications:
- Heart failure from reduced ventricular stroke volume and impaired contractility 1, 3
- Ventricular tachyarrhythmias requiring antiarrhythmic therapy or ablation 2, 1, 3
- Thromboembolism from mural thrombus formation within the aneurysm 2, 1
- Recurrent angina from ongoing ischemia 1, 4
- Mitral regurgitation from altered ventricular geometry 3
Management of Ventricular Aneurysm
Medical Management
Medical therapy should be the initial approach for most patients, with surgery reserved for specific refractory complications. 2
Heart Failure Management
- ACE inhibitors, diuretics, and digoxin form the standard combination for patients with mild to moderate CHF 1
- Optimize guideline-directed medical therapy before considering surgical intervention 3
Anticoagulation for Thromboembolism Prevention
- Warfarin anticoagulation for at least 3 months after acute MI to prevent thromboembolic events 1
- Continue long-term anticoagulation if thrombus persists within the aneurysm 2
Arrhythmia Management
- Electrophysiologic study-guided pharmacotherapy for ventricular tachyarrhythmias 1
- Consider radiofrequency ablation for monomorphic VT related to apical scarring 2
- ICD implantation is indicated for sustained VT/VF occurring >48 hours after STEMI when not due to transient or reversible causes 2
Surgical Management
Surgery for LV aneurysm is rarely needed but should be considered for patients with intractable ventricular tachyarrhythmias and/or pump failure unresponsive to medical and catheter-based therapy. 2
Class IIa Indication (ACC/AHA Guidelines)
It is reasonable that patients with STEMI who develop a ventricular aneurysm associated with intractable ventricular tachyarrhythmias and/or pump failure unresponsive to medical and catheter-based therapy be considered for LV aneurysmectomy and CABG surgery. 2
Specific Surgical Indications
Surgery may be considered for:
- Refractory heart failure despite optimal medical therapy 2
- Ventricular arrhythmias not amenable to drugs or radiofrequency ablation 2
- Recurrent thromboembolism despite appropriate anticoagulant therapy 2
Surgical Technique
- Endoventricular pericardial patch reconstruction with myocardial revascularization represents a safe and reproducible approach 5
- Direct linear closure using Teflon-buttressed interrupted mattress sutures for smaller aneurysms 6
- Meticulous removal of thrombus and everting the edges eliminates thrombogenic surfaces and reduces embolic stroke risk 6
- Surgical techniques should retain ventricular geometry using endoventricular patches to maintain better function 2
Important Evidence Limitation
The STICH trial demonstrated that adding surgical ventricular reconstruction to CABG showed no advantage in terms of survival, rehospitalization, or symptoms compared with revascularization alone. 3 This finding has significantly tempered enthusiasm for routine surgical intervention, making medical management the preferred initial strategy for most patients.
Common Pitfalls to Avoid
- Do not perform prophylactic surgery in asymptomatic patients or those with mild symptoms controlled on medical therapy, given the lack of mortality benefit from the STICH trial 3
- Do not delay ICD implantation in patients with sustained VT/VF occurring >48 hours post-MI, as this provides mortality benefit 2
- Do not stop anticoagulation prematurely in patients with documented mural thrombus, as embolic risk persists 2, 1
- Do not overlook false aneurysms (pseudoaneurysms), which have pericardium as the wall and carry risk of late rupture requiring emergency surgery 1