What is the best treatment approach for a patient with a left ventricular (LV) apical aneurysm, likely secondary to a previous myocardial infarction (MI)?

Management of Left Ventricular Apical Aneurysm

For a patient with LV apical aneurysm post-MI, initiate long-term oral anticoagulation with warfarin (target INR 2.0-3.0) to prevent thromboembolic events, optimize heart failure medical therapy, and strongly consider ICD implantation for primary prevention of sudden cardiac death given the high arrhythmic risk. 1, 2, 3

Immediate Risk Assessment and Anticoagulation

Anticoagulation is mandatory and should be started immediately. The thromboembolic event rate in non-anticoagulated patients with LV apical aneurysms is 1.1% per year, while anticoagulated patients experience no embolic events. 3

• Warfarin remains the standard anticoagulant with target INR 2.0-3.0, particularly when thrombus is present within the aneurysm. 1, 2
• This recommendation applies whether the aneurysm is secondary to MI or occurs in the context of hypertrophic cardiomyopathy. 2, 3
• Duration should be indefinite given the persistent structural abnormality and ongoing embolic risk. 1

Sudden Cardiac Death Risk Stratification

ICD implantation should be strongly considered as these patients carry exceptionally high arrhythmic risk. The sudden death event rate in patients with LV apical aneurysms is 4.7% per year—three-fold higher than HCM patients without aneurysms. 3

• This high risk exists even in the absence of traditional sudden cardiac death risk factors, making LV apical aneurysm itself a major risk marker. 2, 3
• The combined rate of HCM-related deaths plus life-saving aborted events reaches 6.4% per year. 3
• In post-MI patients with LV dysfunction (LVEF ≤30-35%) who are at least 40 days post-MI and NYHA Class I on optimal medical therapy, ICD implantation is reasonable. 1

Medical Management

Optimize heart failure therapy with guideline-directed medical therapy:

• Beta-blockers are first-line for symptomatic patients, though response may be suboptimal in those with apical aneurysms. 2
• ACE inhibitors or ARBs should be initiated for ventricular remodeling prevention. 1
• Consider adding mineralocorticoid receptor antagonists per standard heart failure guidelines. 4
• If beta-blockers are not tolerated, verapamil or diltiazem can be used to reduce LV diastolic pressures and improve filling by slowing heart rate. 2

Management of Ventricular Arrhythmias

For recurrent sustained ventricular tachycardia:

• Catheter ablation should be considered for patients with frequent appropriate ICD therapies or recurrent monomorphic VT related to apical scarring. 1, 2
• Mapping and ablation of the arrhythmic focus can be successful—in one series, 6 patients underwent successful radiofrequency ablation without VT recurrence. 3
• Adjunctive antiarrhythmic therapy with amiodarone or sotalol is reasonable to reduce ICD shocks and improve symptoms. 1

Surgical Considerations

Surgery for LV aneurysm is rarely needed but may be considered for:

• Refractory heart failure symptoms despite optimal medical therapy. 1
• Ventricular arrhythmias not amenable to drugs or radiofrequency ablation. 1
• Recurrent thromboembolism despite appropriate anticoagulation. 1
• Surgery can be performed via transaortic myectomy, transapical approach, or combined incisions with acceptable short-term outcomes. 2

Monitoring and Follow-Up

Serial imaging is essential:

• Monitor for aneurysm growth, thrombus formation, and development of complications. 2
• Echocardiography with contrast enhancement can help rule out associated LV thrombus. 5
• There is no consistent relationship between aneurysm size and adverse events, so all patients require vigilant monitoring regardless of aneurysm dimensions. 3

Critical Pitfalls to Avoid

• Do not withhold anticoagulation even in the absence of visible thrombus—the structural abnormality itself creates ongoing embolic risk. 3
• Do not rely solely on traditional SCD risk scores in patients with apical aneurysms, as they carry high arrhythmic risk independent of conventional risk factors. 2, 3
• Distinguish true aneurysm from pseudoaneurysm, as the latter represents contained free wall rupture requiring emergency surgical repair. 1, 6
• The incidence of LV aneurysm remains 15.92% even in the contemporary primary PCI era, with significantly worse one-year outcomes (MACCEs 15.33% vs 6.44%). 7