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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