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Inferolateral Left
Ventricular Aneurysm
Preventing Mitral Regurgitation
Sakir Arslan, MD
H. Yekta Gurlertop, MD
M. Kemal Erol, MD
Fuat Gundogdu, MD
Huseyin Senocak, MD
A
n 80-year-old asymptomatic man who had experienced an inferior myocardial infarction 2 years earlier was admitted for preoperative cardiovascular
evaluation in preparation for noncardiac surgery. His blood pressure was
140/80 mmHg; his heart rate was 80 beats/min. His electrocardiogram indicated
sinus rhythm, abnormal Q waves, and T-wave inversion in leads aVF, II, and III.
Chest radiography showed cardiomegaly. Transthoracic echocardiography revealed
left ventricular (LV) enlargement, a large (4.8 × 4.6 cm) inferolateral LV wall aneurysm (Fig. 1), and normal left atrial size. It also showed that the posterior mitral
leaflet was tethered by its papillary muscle (Fig. 2). Transesophageal echocardiography (TEE) showed a large LV aneurysm that compressed the mitral annulus (Fig. 3);
it also confirmed the papillary tethering (Fig. 4). Color-flow Doppler TEE showed
minimal mitral regurgitation (MR). The neck of the aneurysm was wide, suggesting
a true aneurysm.
The patient was given an angiotensin-converting enzyme inhibitor, a β-blocker,
aspirin, and spironolactone. Because the patient was asymptomatic and elderly, surgical treatment of the aneurysm was not considered.
Comment
Section Editor:
Raymond F. Stainback, MD,
Department of Adult
Cardiology, Texas Heart
Institute and St. Luke’s
Episcopal Hospital, 6624
Fannin Street, Suite 2480,
Houston, TX 77030
True aneurysm of the LV is the most common mechanical sequela of acute myocardial infarction; it occurs in approximately 15% of all such infarctions (range,
3%–38%). Only 9% of all infarct-related aneurysms involve the inferior wall, and
they are rarely extensive.1,2 Post-infarction LV aneurysm is a serious disorder that can
lead to congestive heart failure, lethal ventricular arrhythmia, and premature death.
Application of Laplace’s law indicates that LV wall tension increases as diameter,
intracavitary pressure, and thinning of the LV wall increase. A large, thin-walled
aneurysm is worsened by high wall tension, poor coronary perfusion, and further
dilation. The ultimate stage of LV aneurysm is enlargement—not only of the aneurysm, but of the entire LV. As a result, most such patients develop heart failure.3 Our
patient had LV dilatation and LV failure.
From: Department of Cardiology, Faculty of Medicine,
Ataturk University, 25070
Erzurum, Turkey
Address for reprints:
Sakir Arslan, MD,
Ataturk Universitesi,
Tip Fakultesi Kardiyoloji
AD, 25070 Erzurum, Turkey
E-mail:
[email protected]
© 2007 by the Texas Heart ®
Institute, Houston
130
Inferolateral LV Aneurysm
Fig. 1 Transthoracic echocardiography shows the inferolateral aneurysm.
A = aneurysm; LA = left
atrium; LV = left ventricle
Volume 34, Number 1, 2007
Fig. 4 Transesophageal echocardiography shows that the posterior mitral leaflet is tethered by its papillary muscle.
Fig. 2 Transthoracic echocardiography shows that the posterior
mitral leaflet is tethered by its papillary muscle.
A = aneurysm; Ao = ascending aorta; LA = left atrium; LV = left
ventricle; X = posterior mitral leaflet
A = aneurysm; LA = left atrium; LV = left ventricle; X = posterior
mitral leaflet
Real-time motion images are available at texasheart.org/journal.
Click here for real time motion image: Fig. 4.
Real-time
motion
images
are available
at texasheart.org/journal.
Click here
for
real-time
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image: Fig. 2.
leaflet coaptation. Consequently, our patient’s aneurysm treated itself.
References
Fig. 3 Transesophageal echocardiography shows the inferolateral aneurysm.
A = aneurysm; Ao = ascending aorta; LA = left atrium; LV = left
ventricle
1. DePace NL, Dowinsky S, Untereker W, LeMole GM, Spagna PM, Meister SG. Giant inferior wall left ventricular aneurysm. Am Heart J 1990;119(2 Pt 1):400-2.
2. Meizlish JL, Berger HJ, Plankey M, Errico D, Levy W, Zaret
BL. Functional left ventricular aneurysm formation after
acute anterior transmural myocardial infarction. Incidence,
natural history, and prognostic implications. N Engl J Med
1984;311:1001-6.
3. Lundblad R, Abdelnoor M, Svennevig JL. Surgery for left
ventricular aneurysm: early and late survival after simple linear repair and endoventricular patch plasty. J Thorac Cardiovasc Surg 2004;128:449-56.
4. Madani MM. Mitral valve repair in the treatment of heart
failure. Curr Treat Options Cardiovasc Med 2004;6:30511.
Mitral regurgitation is a severe problem in patients
with heart failure. The MR is functional and secondary
to both annular and LV dilatation. In general, patients
with lateral wall LV aneurysm have severe MR due to
papillary muscle tethering or annular dilatation. In addition, papillary muscle tethering increases MR and
renders it severe in these patients. Patients with secondary MR experience a worsening of LV function, LV
dilatation, and MR.4 Despite apparent overtethering
of the posterior mitral leaflet due to papillary muscle
displacement, MR was not present in our patient. Presumably, this was due to compensatory systolic expansion of the large aneurysmal cavity, which seemed to
compress the mitral annulus, thereby preserving mitral
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Inferolateral LV Aneurysm
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