Left Ventricular Aneurysm

Left ventricular aneurysm formation following acute STEMI causes persistent ST elevation on the ECG.

ECG Features of Left Ventricular Aneurysm
  • ST elevation seen > 2 weeks following an acute myocardial infarction
  • Most commonly seen in the precordial leads
  • May exhibit concave or convex morphology
  • Usually associated with well-formed Q- or QS waves
  • T-waves have a relatively small amplitude in comparison to the QRS complex (unlike the hyperacute T-waves of acute STEMI)
LV Aneurysm BMJ
Typical LV aneurysm morphology. Reproduced from Edhouse, Brady and Morris

The pattern of persistent anterior ST elevation (> 2 weeks after STEMI) plus pathological Q waves has a sensitivity of 38% and a specificity of 84% for the diagnosis of ventricular aneurysm.


Pathophysiology
  • Following an acute STEMI, the ST segments return towards baseline over a period of two weeks, while the Q waves persist and the T waves usually become flattened or inverted
  • However, some degree of ST elevation remains in 60% of patients with anterior STEMI and 5% of patients with inferior STEMI
  • The mechanism is thought to be related to incomplete reperfusion and transmural scar formation following an acute MI
  • This ECG pattern is associated with paradoxical movement of the ventricular wall on echocardiography (ventricular aneurysm)

Clinical Significance

Ventricular aneurysms predispose patients to an increased risk of:

  • Ventricular arrhythmias and sudden cardiac death (myocardial scar tissue is arrhythmogenic)
  • Congestive cardiac failure
  • Mural thrombus and subsequent embolisation

Causes

The following conditions may cause an LV aneurysm:


Differentiation from acute STEMI

In patients presenting with chest pain and ST elevation on the ECG it is vital to be able to be able to distinguish between LV aneurysm (“old MI”) and acute STEMI.

Factors favouring left ventricular aneurysm
  • ECG identical to previous ECGs (if available)
  • Absence of dynamic ST segment changes
  • Absence of reciprocal ST depression
  • Well-formed Q waves
Factors favouring acute STEMI
  • New ST changes compared with previous ECGs
  • Dynamic / progressive ECG changes — the degree of ST elevation increases on serial ECGs
  • Reciprocal ST depression
  • High clinical suspicion of STEMI — ongoing ischaemic chest pain, sick-looking patient (e.g. pale, sweaty), haemodynamic instability
Other discriminating features

The ratio of T-wave to QRS complex amplitude has been validated as a means of differentiating between LV aneurysm and acute STEMI:

  • T-wave/QRS ratio < 0.36 in all precordial leads favours LV aneurysm
  • T-wave/QRS ratio > 0.36 in any precordial lead favours anterior STEMI

ECG Examples
Example 1
ECG Ventricular Aneurysm

Anterior Left Ventricular Aneurysm:

  • Minimal ST elevation in V1-3 associated with deep Q waves and T-wave inversion
  • This is a LV aneurysm secondary to a prior anteroseptal STEMI
  • Note the T-wave/QRS ratio is < 0.36 in all precordial leads

Example 2
Inferior Left Ventricular Aneurysm 2

Inferior Left Ventricular Aneurysm:

  • Old inferior STEMI with persistent ST elevation (LV aneurysm morphology)
  • ECG is reproduced from Dr Smith’s ECG Blog


References

Advanced Reading

Online

Textbooks


LITFL Further Reading

ECG LIBRARY 700

ECG LIBRARY

Electrocardiogram

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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