MioAtlas
G8: Complications of myocardial infarction

Left ventricular aneurysm with mural thrombus

Chronic circumscribed deformation and bulging of the left ventricular wall (true aneurysm) as a sequela of a previous transmural myocardial infarction.

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Definition

Chronic circumscribed deformation and bulging of the left ventricular wall (true aneurysm) as a sequela of a previous transmural myocardial infarction, composed of fibrotic scar tissue that thins the muscular wall and exhibits akinetic or paradoxical dyskinetic systolic motion with a wide communication base with the cavity [C9] [G810-05].

Severity criteria

  • Literal statement from study of Arvan & Varat [G810-05, Abstract]:
    • «Twenty-three patients with an anterior wall myocardial infarction (MI) and persistent ST-segment elevations (Group I) were examined for wall motion abnormalities using 2-dimensional (2-D) echocardiography»
    • «Twenty-two (96%) had dyskinetic wall motion of the infarcted area and 10 (43%) had a left ventricular aneurysm»
  • Persistent ST elevation: ST-segment elevation persisting after acute phase in anterior precordial leads (V1–V4) with associated pathological Q waves [G810-05].
  • Neck morphometry: Ratio between entry orifice diameter and maximal sac diameter > 0.90 (distinctive wide neck compared to pseudoaneurysm) [C9].
  • Ejection fraction: Reduced ventricular ejection fraction (LVEF < 40%) due to loss of contractile function and dyskinesia [C9].

Findings by layer

Hemodynamics

  • Left ventricular ejection fraction: reduced (< 40%) [C9].
  • Mean pulmonary capillary wedge pressure: moderately elevated (16–20 mmHg) due to systolic dysfunction and elevation of LV end-diastolic pressure [C9].
  • Cardiac output: 3.5–4.5 L/min [C9].

Rhythm

  • Normal sinus rhythm or possible ventricular premature beats originating from fibrotic scar border [C9] [E2].

ECG

  • Pathological Q waves of anterior transmural necrosis (infarct Q waves, V1–V4) with persistent convex ST-segment elevation (persistent ST-segment elevation) and flattened or inverted T waves [C9] [G810-05] [E1].

Heart sounds and murmurs

  • Third heart sound (S3): S3 gallop audible at apex due to rapid ventricular filling into a dilated chamber with systolic dysfunction [C9].
  • Palpation: Characteristic ectopic dyskinetic apical impulse or palpable double apical impulse [C9].
  • Murmurs: Soft ejection systolic murmur or inconstant mid-to-late systolic murmur [C9].

Arterial pulse

  • Pulse of preserved or slightly diminished amplitude [B4].

Jugular venous pulse

  • Generally normal or with moderate elevation if retrograde congestion coexists [B3].

Maneuvers

  • Standard physiological responses to preload and afterload maneuvers in context of ischemic cardiomyopathy [B1].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Normal Sinus Rhythm

Also known as: Left ventricular aneurysm with mural thrombus · Left ventricular aneurysm · Post-infarction LV aneurysm · True LV aneurysm · LV aneurysm

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C9] Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association . Circulation (2021) . DOI: 10.1161/CIR.0000000000000985 PubMed: 34126755
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  7. [G810-05] Persistent ST-segment elevation and left ventricular wall abnormalities: a 2-dimensional echocardiographic study . Am J Cardiol (1984) . DOI: 10.1016/0002-9149(84)90576-9 PubMed: 6731299