Case Presentation: A 78-year-old female with no known cardiac history presented to an emergency room for evaluation of falls with chronic low back pain and was found to be fluid overloaded on exam. She was treated for suspected heart failure exacerbation and pneumonia. Her exam was also notable for a large mass over the left superior orbit which prompted transfer to a tertiary care center for further evaluation. Electrocardiogram showed Q waves in anterior and inferior leads and T wave inversions in anterior, inferior, and lateral leads concerning for prior infarct. An echocardiogram revealed a left ventricular ejection fraction of 25% and thinning, akinesis, and aneurysm of mid-anteroseptal, mid-inferoseptal, and all apical segments. She was diuresed to euvolemia and further cardiac evaluation was deferred due to planned biopsy of patient’s facial lesion, diagnosed later as squamous cell carcinoma.

Discussion: Left ventricular (LV) aneurysm is a known complication following an anterior wall transmural myocardial infarction. It is formed due to necrosis of myocytes within days or due to fibrous remodeling months later. The incidence of LV aneurysms has decreased due to early revascularization therapies leading to preservation of injured myocytes. Patients typically present with cardiopulmonary symptoms and undergo workup for ischemic cardiomyopathy. For patients with concomitant heart failure, guideline-directed medical therapy for neurohormonal blockade is initiated targeting beta blockade, afterload reduction, and decreased collagen remodeling. Anticoagulation is initiated when benefits outweigh bleeding risk in patients with evidence of thrombus, systemic embolization, or with apical or inferobasal akinesis or dyskinesis. Surgical management is not typically recommended but could include endoventricular patch, aneurysmectomy if undergoing thoracic procedure, or heart transplant in severe cases. Studies on mortality report varied data due to differences in kinetics of the aneurysm and extent of coronary artery disease. Thus, follow up echocardiography is recommended every three to six months.

Conclusions: Given the rarity of incidental finding of left ventricular aneurysms, evidence-based guidelines are not apparent. Management should be individualized but focused on referral for ischemic evaluation and consideration for guideline-directed medical therapy and/or anticoagulation.

IMAGE 1: Echo