Left ventricular aneurysm


  • Thin or fibrotic ventricular wall
    • Muscle may be absent or necrotic
    • Akinetic or dyskinetic wall (paradoxical ballooning)


  • Majority
    • Healed transmural MI (anterior or inferior most common)
  • Rare
    • HOCM
    • Chagas

Clinical Features

  • May be asymptomatic
  • History of myocardial infarction
  • Angina
  • Shortness of breath or dyspnea on exertion
  • CHF symptoms
  • Mitral regurgitation murmur
  • S3/S4 heart sounds
  • More common in women than men


  • Heart failure (LV aneurysm steals cardiac output)
  • Angina (increased O2 demand)
  • Ventricular dysrhythmias (LV stretch/scarring)
  • LV thrombus (50% of time), arterial embolism (stroke)
  • LV rupture (rarely occurs in mature LVA because of dense fibrosis)

Differential Diagnosis

ST Elevation



  • ECG
    • Persistent characteristic ST elevation after MI
    • Non-specific ST segment changes
    • Q or QS waves
    • T waves small relative to QRS
    • No reciprocal changes
  • CXR
    • Prominent left heart border
    • Calcified aneurysm
    • May have mass-like appearance
  • TTE
  • LV angiography
  • Cardiac MRI


Differentiate left ventricular aneurysm from STEMI and other causes of ST-elevation

  • Strongly suspect STEMI if:
    • Symptomatic
    • No q waves present (LV aneurysm typically produces significant q waves)
    • Evolving changes on serial ECG
    • Reciprocal changes
  • Consider two rules to differentiate[1]
    • Rule 1
      • If (Sum of T-wave amplitudes in V1-V4) divided by (Sum of QRS amplitudes in V1-V4) > 0.22
      • Suggestive of STEMI, with ~87% accuracy
    • Rule 2
      • If any lead in V1-V4 has T-wave amplitude to QRS amplitude ratio > 0.35
      • Suggestive of STEMI, with ~89% accuracy

STEMI Stages of Development

Stage Duration Timing Finding ECG

30min - hoursHyperacute T waves
  • >6mm limb leads
  • >10mm precordial leads
Normalizes in days, weeks, or months

Minutes - hoursST segment elevation
  • 0.1mV in two or more contiguous leads
ST segment resolution occurs over 72hrs; completely resolves within 2-3wks

Within 1hr; completed within 8-12hrQ wavesPersist indefinitely in 70% of cases


  • Be sure to rule out acute or subacute coronary syndrome

Medical Therapy (first line)

  • Afterload reduction (ACEI)
  • Antianginal (Nitro)
  • Anticoagulation (if LV thrombus)

Surgical Therapy

  • Aneurysmectomy and CABG (and possible valve repair) if ventricular arrhythmias and/or HF refractory to medical therapy


  • Cardiothoracic surgery consultation

See Also


  1. Klein LR, Shroff GR, Beeman W, and Smith SW. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm. Am J Emerg Med. 2015 Jun;33(6):786-90.
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