ECG and Left Ventricular Aneurysm

Left Ventricular Aneurysm (LVA): Overview

Left ventricular aneurysm is a mechanical complication of transmural myocardial infarction, most commonly following an anterior wall STEMI due to LAD occlusion. It represents a thinned, fibrotic, non-contractile segment of myocardium that paradoxically bulges during systole.

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Pathophysiology

Occurs weeks after a full-thickness MI

Infarcted myocardium is replaced by fibrous tissue

The affected segment becomes akinetic or dyskinetic

Leads to persistent electrical abnormalities on ECG

Because the tissue is scarred (not ischemic), ECG changes are fixed and non-evolving.

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ECG Changes in Left Ventricular Aneurysm

1. Leads Involved

Precordial leads (V1–V6) are most commonly affected

Inferior leads (II, III, aVF) are rarely involved unless inferior MI caused the aneurysm

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2. Persistent ST-Segment Elevation

Hallmark ECG feature

ST elevation may be concave or convex

Persists > 2 weeks after STEMI

Unlike acute MI, ST elevation does not resolve

Key Point:

Persistent ST elevation after MI = Think LV aneurysm

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3. Static ECG Pattern

ST-T changes are unchanged over time

No dynamic evolution (unlike reinfarction or acute ischemia)

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4. Absence of Reciprocal ST Depression

Reciprocal ST depressions are typically absent

Helps differentiate from acute STEMI

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5. Pathological Q Waves

Deep, wide Q waves due to transmural myocardial necrosis

Often seen in the same leads showing ST elevation

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6. T-Wave Abnormalities

T waves are flat or inverted

Unlike acute MI, hyperacute T waves are absent

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ECG vs Acute STEMI – Key Differences

Feature Acute STEMI LV Aneurysm

ST elevation Dynamic Persistent

Reciprocal changes Present Absent

Q waves May develop Established

Troponin Elevated Normal or stable

Symptoms Ongoing chest pain Usually asymptomatic

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Clinical Significance

Left ventricular aneurysm is associated with:

Heart failure (↓ ejection fraction)

Ventricular arrhythmias

Systemic embolization (LV thrombus formation)

Sudden cardiac death

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Diagnosis

ECG: Persistent ST elevation with Q waves

Echocardiography: Dyskinetic or akinetic LV segment

Cardiac MRI: Gold standard for scar and aneurysm assessment

Coronary angiography: Defines coronary anatomy

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Management

Medical

ACE inhibitors / ARBs

Beta-blockers

Anticoagulation if LV thrombus present

Guideline-directed heart failure therapy

Surgical (Selected cases)

Aneurysmectomy in:

Refractory heart failure

Recurrent ventricular arrhythmias

Large aneurysms causing embolization

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Take-Home ECG Clues

Persistent ST elevation weeks after MI

No reciprocal ST depression

Deep pathological Q waves

Flat or inverted T waves

Static ECG pattern over time

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