What is Ventricular Aneurysm?
About 1.5 million people in the United States experience a type of heart attack called acute myocardial infarction each year. This condition can lead to several issues such as poor blood flow, mechanical problems, irregular heart rhythms, clots that can travel to other parts of the body, or inflammation. A serious issue that often comes after a heart attack is the development of mechanical complications, which can significantly decrease the chances of recovery in the short and long term.
One commonly occurring issue after a heart attack is a ventricular aneurysm. First reported in 1951, a ventricular aneurysm is a bulge in the weakened muscle wall of the heart. This happens when an area of the heart that is fully damaged by a heart attack turns into non-active, fibrous tissue. Because this portion of the heart can’t contract normally, it bulges outwards during the heart’s pumping phase.
This condition leads to the expansion of a non-functional area of the heart, creating a thin, circumscribed, fibrous and non-contracting pouch. A significant ventricular aneurysm occurs in 30% to 35% of acute transmural myocardial infarction, a type of severe heart attack where the heart’s main artery gets completely blocked.
There are two major risk factors for developing a ventricular aneurysm, including complete blockage of the heart’s main artery and failure to clear the blockage of the artery affected by the heart attack. Importantly, ventricular aneurysms can be of two types – true or false aneurysms. A true aneurysm is a full-thickness bulge of the heart muscle wall. In contrast, a false aneurysm occurs when the heart’s wall ruptures, but the tear is contained by the lining around the heart.
The bottom and front areas of the heart are usually affected by a true ventricular aneurysm, although the base of the heart can also be impacted. The incidence of an aneurysm in the lower-back or side wall of the heart is much lower, about 5% to 10%. Meanwhile, false aneurysms are more likely to involve the back or lower surface of the heart than the apex or side wall.
Most of the time, ventricular aneurysms don’t exhibit symptoms and are detected during routine check-ups. However, symptoms can vary widely, from clots that travel to other parts, irregular heart rhythms, motion abnormalities of the heart wall, heart reattack, fast heartbeat, and even sudden cardiac death.
What Causes Ventricular Aneurysm?
A ventricular aneurysm is a condition where a part of the heart bulges out abnormally. This bulge or “aneurysm” occurs in one of the heart’s lower chambers, the ventricles. There are different reasons why this can happen:
Some people are born with the condition, which is referred to as a congenital aneurysm. These are usually large, filled with unclotted blood, and connected to the ventricular cavity by a wide channel. The aneurysm is lined with thin fibrous tissue.
Acquired aneurysms, on the other hand, develop later in life due to certain conditions or incidents. There are a few types:
- Ischemic aneurysms: The most common type, making up about 85% to 90% of all ventricular aneurysms. These are usually caused by a heart attack affecting the wall of the heart.
- Traumatic aneurysms: These are caused by injuries to the heart, either from accidents or surgeries.
- Infective aneurysms: These are caused by infections like infective endocarditis, rheumatic fever, syphilis, tuberculosis, and others.
Another rare type of aneurysm is the idiopathic aneurysm, where doctors can’t pinpoint a specific cause. This type happens more often in Africans and sometimes in white people. The aneurysm usually appears near the mitral ring, a part of the heart close to the mitral valve. This can result in issues with parts of the heart, such as the papillary muscle, chordae tendinae, and the flaps of the mitral valve.
In some cases, a ventricular aneurysm can happen after childbirth due to a condition called postpartum cardiomyopathy. There are certain factors that can increase the risk of developing an aneurysm, such as high blood pressure, steroid use, and using non-steroidal anti-inflammatory medications.
Other potential causes of a ventricular aneurysm include diseases like Chagas disease and sarcoidosis.
Risk Factors and Frequency for Ventricular Aneurysm
The Coronary Artery Surgery Study (CASS) found that out of 15,000 patients, 7.6% had a left ventricular aneurysm. Furthermore, in cases of anterior wall myocardial infarction, these aneurysms were detected in 22% of patients within 3 months of the infarction. This type of aneurysm contributes to high heart-related death rates, ranging around 67% in 3 months and increasing to 80% after a year.
Signs and Symptoms of Ventricular Aneurysm
A small ventricular aneurysm, an abnormal bulge in the wall of your heart’s largest pumping chamber, is usually symptom-free and is often found during regular health check-ups. Larger aneurysms, however, can lead to severe symptoms and dangerous health conditions including blood clots, heart rhythm problems, and in worst cases, sudden cardiac death.
Common symptoms of a ventricular aneurysm include:
- Fatigue
- Shortness of breath
- Chest pain
- Heart palpitations
- Fainting
- Swelling of ankles, feet, or abdomen due to fluid build-up
- Stroke, or blood clot affecting an organ in the body
- Reduced blood supply to an arm, leg, or organ
During physical examination, you might exhibit these signs indicating the presence of a ventricular aneurysm:
- Fast heart rate
- Irregular heart rhythms
- Rubbing sound in the heart due to inflammation of the pericardium
- Abnormalities in cardiac impulse
- An unusual splitting of a certain heart sound (S2)
- Possible presence of a third heart sound (S3)
- Swelling or fluid retention in the lower extremities (pedal edema)
- Abnormal lungs sound (fine inspiratory basal crept)
- Unusual heart sounds (murmurs)
The complications linked with an LV aneurysm are diverse. These involve:
- Heart failure and decreased blood supply to your body (Ischemia): The enlarged heart and unusual motion due to the aneurysm cause these conditions.
- Abnormal heart rhythms (Ventricular Arrhythmias): The aneurysm site can generate erratic heart rhythms leading to sudden cardiac death.
- Increased formation of blood clot (Thromboembolization): The aneurysm can cause blood to pool and clot, increasing the risk of stroke.
- Bursting of the aneurysm (Ventricular Rupture) and fluid build-up around the heart (Cardiac Tamponade): This is more likely to happen in immature aneurysms.
Testing for Ventricular Aneurysm
To detect and understand more about a condition called Left Ventricular (LV) Aneurysm, there are several exam methods that your doctor could use:
Electrocardiogram (ECG): An ECG is a simple test that checks your heart’s rhythm. In the context of identifying LV Aneurysm, certain abnormal features may be detected. These include strong R waves in a specific reading called AvR, ongoing elevation in the line normally observed in an EKG (ST-segment) with T waves turning the opposite direction than expected, and small R waves in areas related to the functioning of the left ventricle. Sometimes, the EKG might also show signs of abnormal heart rhythms which could be linked to LV Aneurysm.
Chest Radiograph (x-ray): A chest x-ray is a standard imaging test where a picture of the structures inside your chest, like your heart, lungs and blood vessels, is created. For someone with a LV aneurysm, the x-ray could show an unusual shadow or opacity that extends beyond the regular outline of the heart.
Computed Tomography (CT scan): Another imaging test, a CT scan could be used to get information about the aneurysm wall and to check for any blood clots on the aneurysm wall. It allows for detailed viewing of the heart. However, there is a small risk of developing kidney issues (contrast-induced nephropathy or CIN) due to the contrast dye used in the test. To reduce this risk, your doctor may recommend that you drink plenty of water before having the test.
Magnetic Resonance Imaging (MRI): An MRI is a type of scan using strong magnetic fields and radio waves to produce detailed images of the inside of body. It can give accurate a picture of the shape, size, and location of an LV aneurysm, providing valuable information to help guide treatment decisions.
Echocardiography: Using ultrasound waves, this test creates images of the heart and allows the doctor to actually see it beating. This helps them to identify a ventricular aneurysm and even to differentiate between the true aneurysm and a false aneurysm. Other features such as abnormal flow within the aneurysm and thrombus (blood clots) can also be detected with this test.
Nuclear Imaging: This test, utilizing small amount of radioactive materials, creates images of your heart, indicating if an LV aneurysm is present.
Angiography: This test uses x-ray imaging to observe the blood flow in an artery or vein. It is considered the most precise method to diagnose and determine the location of LV aneurysms. If there is a blood clot present, this test can also pick that up.
All these tests can provide a comprehensive evaluation and information about your condition. Your doctor will determine which tests are appropriate based on your health history and symptoms.
Treatment Options for Ventricular Aneurysm
Managing an LV (left ventricular) aneurysm involves either medical or surgical approaches.
In medical management, small to large LV aneurysms that aren’t causing any symptoms can be monitored closely, and patients can expect a survival rate of up to 90% after five years. The plan might include reducing the risk factors for heart disease to prevent decreased blood flow to the heart, reducing the strain on the heart using certain types of medications, and prescribing blood thinners to prevent blockages caused by blood clots. If the aneurysm is large and causing symptoms, the same strategies might be used, along with treatments specific for the accompanying symptoms. Surgery might be considered if it’s necessary. For blood thinners, these are typically given in the first three months following an LV infection because there’s a high risk of blood clot formation within this time. Prolonged use of blood thinners should be reserved for patients who have large, crumbly blood clots protruding into the heart cavity, have experienced systemic embolization beyond three months, or those who have significantly impaired LV function.
In cases where surgery is required, there are numerous possible reasons, including significant growth of the aneurysm, unbearable chest pain, congestive heart failure, arrhythmia (irregular heartbeat), rupture of the aneurysm, formation of a pseudoaneurysm (a false aneurysm), congenital aneurysm (present at birth), or embolism (a blocked artery).
Before heading to surgery, a patient will need to undergo a thorough investigation to evaluate the heart condition. This includes tests to visualize the heart and its vessels, and examination of the mitral valve which lies within the heart.
The surgical procedure involves removal of the aneurysm and restoring the structure of the heart. This can only be done while on a heart-lung machine, with the goal of carefully reducing the size of the heart’s main pumping chamber or left ventricle.
In the past, the surgical approaches used for patients with LV aneurysm and unmanageable irregular heartbeats were stopped due to high chances of operative death. Nowadays, more sophisticated techniques are being used that involve locational mapping of the site causing the irregular heartbeats in the LV aneurysm. This technical procedure consists of removing the aneurysm and a thin layer of damaged tissue around the heart attack area. This method has shown to eliminate irregular heartbeat in 90% of patients, with a risk of operative death of about 10%.
However, surgery isn’t always the best choice, particularly for individuals with higher anesthesia risk, poor heart function, very low blood flow rate, serious mitral valve leaking, signs of a heart attack damaging the innermost layer of the heart wall, or the absence of a thin-walled aneurysm with clear boundaries.
Regarding pseudoaneurysms, which are false aneurysms or a contained tear of the inner layer of the heart wall, not treating them can result in a death rate of up to 50%. Surgery is generally the favored treatment for pseudoaneurysms, but it comes with an up to 10% chance of death during the surgery. An alternative option to open surgery is using a less invasive method where a closure device is inserted through a large blood vessel in the groin.
What else can Ventricular Aneurysm be?
A ventricular aneurysm, a bulge in the wall of your heart’s main pumping chamber, can seem like a number of other heart-related conditions. Some of these conditions include:
- Angina pectoris (chest pain due to reduced blood flow)
- ST-elevation myocardial infarction (a serious type of heart attack)
- Left ventricular pseudoaneurysm (a false aneurysm in the heart’s main pumping chamber)
- Ventricular wall rupture (a tear in the heart wall)
- Pericarditis (inflammation of the heart lining)
- Myocarditis (inflammation of the heart muscle)
- Cardiac tamponade (pressure from fluid buildup in the heart sack)
- Myocardial trauma (heart injury)
- Takotsubo cardiomyopathy (a temporary heart condition often brought on by stress)
What to expect with Ventricular Aneurysm
The long-term effects and predictions for people with ventricular aneurysms are hard to determine because most of the findings come from looking back at patient files (retrospective data) and studying bodies after death. In two studies examining deceased patients, they estimated the age of the aneurysm using past medical files and found that the 5-year death rates were 30 and 80%. More people died due to a repeat heart attack rather than heart failure.
In clinical studies, the future health of the person depends on the size of the aneurysm and if they show symptoms. In one study, the 5-year death rate was 50% overall, but just 10% in those with small aneurysms.
In another ongoing study, the CASS study, over four years, about 71% of those with angiographic LV aneurysms survived. Death was more likely in patients with significant coronary (heart) disease and impaired LV (left ventricular) function. However, just having an aneurysm did not add to the risk of death.
There is a continuous debate over whether surgical removal of aneurysm changes the long-term course of the condition. Formal studies comparing the traditional and surgical approaches are still needed.
The latest results show that the 5-year survival rate after surgery is between 68 to 79% with only a 10% rate of operative death. For those treated using traditional methods, the survival rate over five years is slightly lower, between 66.7 to 70%.
In the CASS study, they found that surgery improved survival, but only in certain high-risk groups like those with triple-vessel disease. From this study, it appears that survival is mainly determined by revascularization (restoring blood supply), and not by removing the aneurysm. Another research showed that the 7-year survival rate was 65% for those who underwent complete revascularization, compared to 50% for those with incomplete revascularization.
An ongoing randomized trial called STICH (Surgical Treatments for Ischemic Heart Failure) may provide more definitive data about the effects of surgical intervention for ventricular restoration on survival, heart size and function, quality of life, and ability to exercise.
Possible Complications When Diagnosed with Ventricular Aneurysm
: A left ventricular aneurysm, or an abnormal bulge in a heart’s chamber, can lead to various complications. These include severe irregular heart rhythms, heart failure, inadequate blood supply to the heart, blood clots travelling to other parts of the body, and fatal breaks in the heart wall. About a third of patients with these aneurysms experience irregular heart rhythms. These specific areas causing the rhythms typically lie between the normal and abnormal heart muscle and can often be identified using an endocardial mapping technique. However, this technique might fail to pinpoint the exact location in patients suffering from changing irregular heart rhythms or those who have had a heart attack in the last six weeks.
Moreover, in-hospital repair of a ventricular aneurysm can also lead to complications, such as:
- Low output of blood from the heart
- Ventricular arrhythmias (irregular heart rhythms)
- Failure of the respiratory system
- Bleeding
- Dialysis-dependent kidney failure
- Stroke
Recovery from Ventricular Aneurysm
Critical care after heart surgery is challenging and often requires changes according to the patient’s condition. For successful recovery, post-operation care is essential, including proper fluid replenishment, suitable medication to support heart function, warming the body, preventative actions against deep vein blood clots and bed sores, and aiding with breathing machines.
Heart surgery patients often experience adverse physical and emotional impacts due to heart-related events. This puts them at the forefront for cardiac rehabilitation — a specialized program aimed at preventing the repeat of such events. The main objective of this program is to curtail the adverse physical and emotional effects of heart disease. The program attempts to decrease the risk of another heart attack or sudden death.
The program typically focuses on alleviating heart disease symptoms and slowing down the hardening of arteries by incorporating exercise routines, educating about the condition, providing counselling, and modifying risk factors. The ultimate goal is to help patients with heart disease return to their normal lives, actively participating in family and social activities.
Preventing Ventricular Aneurysm
Living day-to-day after experiencing a heart attack can be a difficult task for anyone. Challenges such as adjusting to new medications, dealing with possible side effects, and the financial and social impacts that come with these changes can feel overwhelming. Heart attacks are the leading cause of ventricular aneurysms – or dangerous bulges in the heart’s chambers. So, a treatment plan after experiencing a heart attack is important. This plan includes educating the patient about their condition, communication about their wellbeing, and recommending exercise, all aimed to improve the patient’s health situation and reduce the chances of another heart attack.
A strong commitment to a rehabilitative routine, which includes taking prescribed medication, treating other health issues they may have, changing their lifestyle (like diet and weight loss, if needed), and regular check-ins with their primary health carer, can greatly improve their health situation and overall quality of life. All these together help in preventing complications after a heart attack, such as ventricular aneurysms.