Congenital left ventricular aneurysm (LVA) was first described in 1816.1 It is a rare cardiac malformation, defined as a protrusion from the ventricular cavity with a wide connection (ratio of the connection to the body of the anomaly >1) and without contractility, which may present with an akinetic or dyskinetic movement during systole.2 Ohlow et al.3 reported the prevalence of congenital left ventricular aneurysms and diverticulum as 0.76% in a coronary angiogram population.

According to a recent review congenital left ventricular aneurysms are asymptomatic in 41.8% of patients,4 but can be associated with heart failure, arrhythmias, systemic embolization and sudden death due to ventricular rupture.2,5

Ventricular tachycardia may be present in 18.4% of patients with LVA,5 but few data are available concerning these patients’ clinical outcome. Treatment of ventricular tachycardia (VT) in patients with congenital aneurysms can be difficult, and surgical and electrophysiological strategies have been described.6–8

Our case documents a rare case of monomorphic VT in a young patient with a congenital left ventricular apical aneurysm, diagnosed by a multimodality imaging study, and our treatment options.

A 34-year-old male, a regular sports player, presented to our department due to palpitations that had started while playing tennis. He had a past history of Hodgkin lymphoma treated by chemotherapy eight years before, with no evidence of recurring disease.

Previous to the documented episode the patient described two episodes of self-limited palpitations, the first four years previously while playing table tennis, and another eight weeks before the described episode during an argument. He had no family history of sudden death, syncope, ventricular arrhythmias or cardiomyopathy.

On the day that he presented to our department an electrocardiogram (ECG) was performed (Figure 1), which revealed monomorphic ventricular tachycardia with right bundle branch block morphology and superior axis, with a ventricular rate of 256 bpm. As the patient was stable, amiodarone infusion was started, achieving sinus rhythm. His ECG in sinus rhythm showed no changes (Figure 2). The echocardiogram (Figure 3A) revealed no structural abnormalities and the physical examination and laboratory tests showed no remarkable findings.

Figure 1.

Electrocardiogram of clinical ventricular tachycardia (256 bpm).

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Figure 2.

Resting electrocardiogram exhibiting sinus rhythm (60 bpm) and nonspecific repolarization changes.

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Figure 3.

Multimodality imaging of the left ventricular apical aneurysm. (A) Echocardiogram, 4-chamber view, showing no remarkable changes; (B) cardiac magnetic resonance imaging with late gadolinium enhancement depicting myocardial delayed enhancement restricted to the wall of the left ventricular apical aneurysm; (C) cardiac magnetic resonance imaging at end-systole demonstrating the lack of systolic thickening of the left ventricular apical aneurysm wall; (D) computed tomography image of the left ventricle clearly showing the thinning of the left ventricular aneurysm wall compared to the surrounding myocardium.

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In order to exclude structural cardiac abnormalities it was decided to perform cardiac magnetic resonance imaging (Figure 3B and C) that exhibited a left ventricular apical aneurysm: “a saccular apical formation with a thin wall on late gadolinium enhancement, without any scarring of the surrounding myocardium”. He underwent computed tomography coronary angiography that excluded coronary disease and described the same left ventricular apical formation (Figure 3D).

After the diagnosis it was decided to perform an electrophysiological study to determine the origin of the VT and to perform catheter ablation. It was possible to induce VT similar to the clinical VT during the electrophysiological study, and electroanatomical mapping was performed (Figure 4). The reentry circuit and exit point of the tachycardia were inside the aneurysm. Radiofrequency applications were performed with an open-irrigated ablation catheter, targeting diastolic potentials during VT, the tachycardia being terminated during applications. Additional radiofrequency applications were performed in sinus rhythm targeting the exit point of the clinical VT with pace mapping. Radiofrequency applications were limited to 30 W, with a total time of 7 min. At the end of the procedure VT was no longer inducible. Despite this success, it was decided to place a subcutaneous implantable cardioverter-defibrillator (ICD).

Figure 4.

(A) Three-dimensional electroanatomic image of the left ventricle acquired during electrophysiological study. It can be seen that the ventricular tachycardia was localized to the apical aneurysm and the radiofrequency applications; (B) diastolic potentials at the ablation catheter (MAP), and interruption of ventricular tachycardia during radiofrequency applications.

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Eight months after the ablation procedure the patient presented to the emergency department complaining of ICD shocks, due to ventricular tachycardia. He was put on amiodarone 100 mg and bisoprolol 5 mg once daily. The amiodarone dosage was increased and the possibility of performing an aneurysm resection or a reablation procedure was discussed with the patient.

Diagnosis and treatment of VT are often a challenge. This case describes a patient with a left ventricular apical aneurysm with no coronary disease, and late gadolinium enhancement on the aneurysm wall suggesting a fibrotic wall. Fibrotic apical congenital aneurysms have been described previously, being the most probable diagnosis in this case.4 Radiofrequency ablation was the treatment selected for this patient's VT. Successful use of this technique was reported by Haegeli et al. in two of three patients.9 ICD implantation is recommended in patients with VT and structural cardiac abnormalities, and so, despite the good acute result of radiofrequency ablation in this case, a subcutaneous ICD was implanted. This choice was made considering that this was a young patient who had undergone VT ablation and that recurrence of ventricular arrhythmias was likely. However, the question arises whether the advantages of a subcutaneous device in a young patient, particularly the lower risk of long-term complications related to intravascular lead complications,10 outweigh the benefits of antitachycardia pacing with a conventional ICD. Our patient was symptom-free for eight months after the ablation and then needed two appropriate ICD shocks due to VT.

As surgical resection of ventricular aneurysms has been described, with good results, as an alternative treatment for patients with recurrent symptoms, we are considering this option for this patient.4

The authors consider this case relevant due to the rarity of the condition and because there are few cases described in the literature of patients treated with electrophysiological study and ICD implantation. To our knowledge this is the first case in which a subcutaneous ICD was implanted. There is a lack of evidence concerning the management of congenital LVA and more data are needed in this field.

The authors have no conflicts of interest to declare.