Heart aneurysm: how to recognize, treat with and without surgery

A cardiac aneurysm is a very dangerous pathology, which consists of the appearance on one of the heart walls or partitions of a weakened, limited area of muscle tissue that is unable to resist the pressure of the blood and begins to bulge outward or bulge and collapse alternately depending on the phase of the cardiac cycle.

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Diagnostics cardiac aneurysms

The formation of a cardiac aneurysm may be accompanied by the appearance of the following symptoms:

• unusual weakness due to congestion in the heart, as a result of which it pumps an insufficient volume of blood, which means that the nervous system and muscles experience a deficiency of the oxygen they need, which comes to them with the blood,
• paroxysmal pain behind the breastbone (does not always occur),
• increased or decreased heart rate (more than 100 or less than 60 beats per minute),
• irregular heart rhythm with short-term pauses,
• a disturbance in the breathing rhythm called dyspnea,
• pale skin tone (especially on the face and limbs), which is typical for heart pathologies in which there is a disruption in the blood supply to the tissues,
• dry, unexpressed cough due to compression of the lung (with large aneurysms),
• a sensation of a strong heartbeat due to a disturbance in the rhythm or increased contractions of the heart muscle (characteristic of an aneurysm of the left ventricle of the heart).

But the insidiousness of a cardiac aneurysm is that the above symptoms may be present in full (with large aneurysms), partially, or completely absent. The latter not only complicates diagnosis, but also leads to the fact that doctors discover the aneurysm by accident, when it has already reached a significant size and its treatment becomes difficult.

It is difficult to blame doctors for this, because they are guided primarily by the complaints of patients. But if nothing bothers the patient, it is unlikely that he will want to undergo an expensive examination just in case something is found.

In the vast majority of cases, doctors have to deal with the diffuse form of aneurysm of small and medium sizes. The course of the disease in this case is not overshadowed by unpleasant and alarming symptoms. Patients, not feeling ill, sometimes do not take their disease seriously, allowing themselves to skip preventive examinations with a cardiologist.

Examination of the patient

But these are all nuances. In practice, when a patient comes to a doctor with or without complaints, the diagnosis of a cardiac aneurysm begins with a physical examination, and then the patient is offered to undergo further examination. If a person first goes to a therapist with symptoms that worry him, then later, if heart disease is suspected, he will be redirected to a cardiologist, who will continue the examination, make a diagnosis and, if necessary, prescribe appropriate treatment.

During a physical examination of a patient, the doctor performs 4 mandatory procedures: palpation, percussion, auscultation and blood pressure measurement.

Palpation of cardiac aneurysm is justified by the fact that in most cases the aneurysm itself is located either on the anterior wall or at the apex of the left ventricle, located in close proximity to the anterior chest wall. During palpation, the doctor can feel the difference between the pulsation of the healthy part of the heart and the aneurysm (the so-called rocker symptom).

The impact of the upper part of the left ventricle on the chest wall is called the apical impulse, which is determined only in 70% of healthy people. But here, not only the presence of the impulse itself plays a role, but also its diameter. An aneurysm may be indicated by both the appearance of the apical impulse, if it was not previously felt, and an increase in its diameter (over 2 cm). In addition, the force of the impulse in an aneurysm is noticeably reduced.

Percussion is nothing more than tapping the chest with a finger to determine the borders of the heart. In the area of a significant aneurysm, the borders will be slightly shifted, and the sound in this area will be muffled.

Auscultation is listening to sounds in the heart area using a stethoscope. An aneurysm may be indicated by a murmur during systole and the so-called "mouse" noise when blood flows through the mouth of the aneurysm.

Measuring blood pressure is important in various pathologies of the cardiovascular system. In the case of a heart aneurysm, blood pressure is usually elevated, and the prognosis of the disease largely depends on the value of blood pressure indicators.

During a physical examination of the patient, the doctor may discover some signs indicating the possible development of an aneurysm. This gives him every reason to prescribe a more in-depth instrumental examination.

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Instrumental diagnostics

The main methods of instrumental diagnostics for cardiac aneurysm include:

• Electrocardiography. Yes, such a widespread and fairly old diagnostic method as ECG for cardiac aneurysm has been one of the leading ones for many years. Thanks to its general availability and low cost, anyone who cares about how their heart works can undergo the examination.

The device records the conductivity of bioelectric impulses in various parts of the heart muscle, which makes it possible not only to detect the appearance of an aneurysm, but also to determine its location.

An ECG is mandatory for some time after a myocardial infarction, which is a common cause of aneurysm. If during the first month the ECG shows no normal dynamics (frozen ECG), a jump in the ST segment, a lack of the last negative tooth (designated as T), signs of abnormal heart rhythm, this most likely indicates the development of an acute or chronic (indicators persist for more than 1.5 months) aneurysm.

• Echocardiography, otherwise known as ultrasound of the heart. This method is considered the main diagnostic method for cardiac aneurysm, as it allows for a diagnosis with 100% accuracy.

Thanks to the reflection of ultrasonic waves from obstacles of varying density, it is possible to obtain an image of the heart on the screen in the form of a simple or three-dimensional picture.

This method allows visual assessment of the aneurysm (size and configuration) and also reveals blood clots inside it. Moreover, it is possible to detect even small aneurysms by thin areas of the myocardium and lags from the normal heart rhythm. It is possible to see even small aneurysms that are visualized only in the systole phase, and blood in the pericardium. EchoCG can be used to assess the width of the isthmus (to exclude a false aneurysm), the work of the heart valves, the size and volume of the ventricles and atria, and blood flow characteristics.

• PET myocardial scintigraphy, based on the introduction of a contrast agent into the bloodstream that does not accumulate in the aneurysm cavity (or, conversely, accumulates only in this area), which makes it easy to detect the weakened area of the heart. This method is considered more complex and expensive, and it also provides less information than ultrasound, so it is used much less often.

To determine the viability of the affected area of the myocardium, this method can be used in parallel with stress echocardiography, when a stressful situation is artificially created by administering drugs or under the influence of physical activity.

• X-ray, which is used only in cases where it is not possible to conduct a more informative examination. An X-ray will show the borders of the heart and large aneurysms, while small ones will remain unnoticed. Based on the results of the examination, it is possible to see an increase in the size of the heart and congestion in the pulmonary circulation.

Additionally, the patient may be prescribed the following tests:

• Ventriculography (X-ray examination of the ventricles of the heart using contrast agents).
• CT or MRI of the heart (scanning of the heart using x-rays or radio waves).
• Sounding of the heart cavities using a cardiac catheter.
• Coronary angiography (blood flow assessment).
• Electrophysiological study (EPS) of the heart.

In addition, the patient is prescribed some types of tests, such as general and biochemical blood tests (for markers of necrosis present in myocardial infarction), general urine analysis to diagnose possible concomitant pathologies.

ECG for cardiac aneurysm

Since the electrocardiographic examination method is very popular for various cardiovascular diseases, it makes sense to dwell on it in more detail. Although this method does not provide a 100% guarantee of detecting a cardiac aneurysm, it does allow us to detect disturbances in the functioning of the heart, which in itself is a reason for a more thorough examination of the patient and his further observation by a cardiologist.

The ECG procedure is inexpensive, but available in literally all hospitals and clinics. A person immediately receives a cardiogram, however, the decoding of the results will have to be entrusted to an experienced therapist or cardiologist, since they do not carry any useful information for a non-professional.

Indications for the procedure may include both suspected cardiovascular pathologies and examinations in connection with diseases of the nervous system, various internal organs, skin, etc. It is also performed during preventive examinations of patients registered with a cardiologist, as well as when complaints about heart function arise.

Sometimes professional activity requires an ECG with interpretation of the results. Then this item is included in the professional examination form.

An ECG is also recommended before surgical interventions, especially if anesthesia is required.

In case of cardiac aneurysm, the ECG is performed in the usual mode. The patient undresses to the waist and removes clothing from the lower part of the legs. After this, he lies down on the couch, and the doctor attaches several electrodes to the body in the area of the heart, hands and shins, ensuring their complete adhesion. The device registers electrical impulses coming from electrodes located in different parts of the body and records them on paper.

The medical professional performing the procedure tells the patient when to breathe calmly and evenly and when to hold their breath.

ECG is considered one of the safest and most accessible procedures that cannot harm the body. The patient is not exposed to radiation or high-power current, so even the skin does not suffer, not to mention the internal organs.

Changes in the cardiogram allow the doctor to see how the patient's heart is working and how large and dangerous the disturbances in its functioning are.

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Differential diagnosis

Since the clinical picture of a cardiac aneurysm is quite vague, and its symptoms may indicate both the aneurysm itself and other diseases, it is necessary to carefully study the results of the studies and compare them with the picture that is observed in other pathologies with similar symptoms.

Differential diagnosis of cardiac aneurysm is carried out with the following pathologies:

• Coelomic cyst of the pericardium, when a thin-walled “sac” with liquid contents forms on the pericardium, which can rupture and cause purulent processes in the heart.
• Mitral heart defect. In other words, it is a defect of the mitral (bicuspid) valve, which connects the left atrium and ventricle, affecting the blood flow. Narrowing of the mitral valve causes symptoms similar to a heart aneurysm.
• Tumor processes in the mediastinum. If the tumor is located near the heart, it can distort the information the doctor receives during palpation and percussion. But its symptoms can also indicate a heart aneurysm: shortness of breath, cough, chest pain, weakness, etc.

Usually, the situation is clarified by radiography and tomography of the heart, which help to identify other pathologies, even those that are not directly related to the work of the heart. The doctor makes a final diagnosis based on the results of a physical examination of the patient and the studies conducted after that.

Treatment cardiac aneurysms

Drug therapy is relevant if we are talking about a diffuse flat aneurysm, which is not prone to rupture. It is also carried out for preventive purposes to prevent rupture of the cardiac aneurysm, as well as in the preoperative period.

In principle, if the aneurysm does not grow and no blood clots form in its cavity, there is no need to rush with the operation. Symptomatic treatment, prevention of complications and regular examinations by a cardiologist are usually sufficient.

There is no rush to perform surgery in cases where an aneurysm is detected in newborns. In such cases, surgical treatment is performed after the baby turns one year old. Until that time, supportive therapy can be practiced.

Drug treatment of cardiac aneurysm is also indicated if the patient cannot undergo surgery for various reasons (for example, the person does not tolerate anesthesia well or has been diagnosed with severe mitral insufficiency) or he himself refuses surgical treatment. In this case, the person will have to take the drugs prescribed by the doctor for the rest of his life.

Drug treatment, as a rule, pursues two goals: reducing the load on the cavity of the heart in the wall of which the aneurysm has formed, and preventing thrombus formation.

Treatment of cardiac aneurysm without surgery involves taking the following groups of drugs:

• β-blockers, which regulate the strength and rhythm of heart contractions,
• thrombolytic drugs that prevent the formation of blood clots by thinning the blood and preventing platelets from sticking together,
• diuretics (water pills) that help reduce high blood pressure, which is dangerous in terms of triggering aneurysm rupture,
• nitrates, popular as effective drugs for angina pectoris, dilating coronary vessels, improving myocardial nutrition and preventing the development of heart failure.

Which drug from each specific group the doctor will prescribe depends on the patient's age and condition. Advice and recommendations in this case can only do harm, complicating the situation with a ruptured aneurysm or the development of heart failure, which will make surgical intervention mandatory.

There have been cases where doctors did not have to apply any treatment, because the aneurysm was no longer diagnosed after a while. A fair question arises: can a heart aneurysm disappear? But there is no clear answer to it.

Usually, the disappearance of an aneurysm is associated with childhood. If the aneurysm appeared in the prenatal period, it is unlikely to disappear over time. If the child was simply born with abnormal heart tissue development, and the appearance of an aneurysm is associated with the need to breathe independently, scream and perform other actions that contribute to increased pressure in the vessels and heart, weak tissues that bend under the load can eventually come into tone. This means that the aneurysm will disappear. However, there will remain a risk of its recurrence, for example, if the child periodically suffers from viral or bacterial infectious diseases.

In adult patients who have had a myocardial infarction, an aneurysm may develop in the acute period of the disease. And when the affected tissues become scarred, the aneurysm either disappears or becomes chronic.

Physiotherapy treatment for cardiac aneurysm is usually performed after surgery. Most physical procedures are contraindicated for cardiac aneurysm, especially in its acute form, so the doctor should approach the choice of physiotherapy methods with special caution.

After surgical removal of a cardiac aneurysm, procedures such as electrosleep, galvanotherapy and electrophoresis with the use of vasodilators and pain-relieving drugs may be prescribed.

To prevent the development of aneurysms and other complications after a myocardial infarction, magnetic therapy and various balneotherapy procedures (mineral, nitrogen and oxygen baths) can be used.

Drug treatment

So, we already know that several types of drugs are used to treat the dangerous symptoms of cardiac aneurysm. These are beta-blockers, thrombolytics, diuretics, nitrates and, of course, vitamins that support our body during illness.

The choice of effective drugs in case of non-operable cardiac aneurysm always remains with the attending physician, so it is impossible to say for sure which drug is better and which is worse. We will give only a few names of drugs from each group that can be prescribed for the treatment of rhythm disturbances, lowering blood pressure, preventing thromboembolism and improving blood circulation in cardiac aneurysm.

Beta-blockers: Propranolol or Anaprilin, Bisoprolol or Bicard, Nebivolol or Nebilet, Carvedilol, etc. These drugs reduce the manifestations of heart failure and blood pressure. They are not prescribed for bronchial asthma, bradyarrhythmia, symptomatic hypotension, second-degree atrioventricular block, acute heart failure, or during pregnancy. They are not used in pediatrics.

Thrombolytics: Alteplase, Fibrinolysin, Tenecteplase, Urokinase-plasminogen, Eminase, etc. Contraindicated in cases of bleeding, suspected pericarditis, aortic aneurysm dissection, uncorrectable high blood pressure, and some other pathologies. Not used during pregnancy.

Diuretics: Furosemide, Torasemide, Spironolactone, Xipamide, Ethacrynic acid, Indapamide, Ezidrex, Arifon, etc. Preference is given to thiazide drugs that maintain blood pressure at the desired level; if necessary, switch to loop diuretics. Contraindications may include liver and kidney dysfunction, as well as pregnancy.

Nitrates (nitrovasodilators): "Nitroglycerin", "Isosorbide dinitrate", "Molsidomine", "Isosorbide mononitrate". Contraindicated in case of low blood pressure and pulse, severe tachycardia and contractile dysfunction of the right ventricle of the heart.

Surgical treatment

The main and most preferred way to combat cardiac aneurysm is considered to be its surgical treatment. But it is important to understand that cardiac aneurysm plastic surgery has nothing to do with suturing a skin wound. This is a serious and rather dangerous operation, the mortality rate of which can range from 5 to 10%. Therefore, in the case of asymptomatic left ventricular aneurysm, doctors do not insist on surgery.

Indications for surgical treatment of aneurysm are:

• the appearance of dangerous symptoms associated with rapidly developing heart failure,
• severe cardiac arrhythmias that are not amenable to drug correction,
• the formation of blood clots in the aneurysm cavity (especially if there has already been a situation with a blood clot breaking off and blocking the vessels),
• akinetic aneurysm, in which the end-systolic index exceeds 80 ml per m2 ^, and the end-diastolic index is greater than 120 ml per ^m2,
• increased risk of developing a false aneurysm, which is dangerous due to the high probability of bleeding,
• rupture of an aneurysm, which is considered the most dangerous complication of a cardiac aneurysm and leads to oxygen starvation of the entire body due to severe bleeding, which often ends in the death of the patient.

All of the above situations are potentially life-threatening, not to mention that they significantly complicate the work of the heart and negatively affect the well-being of patients. If we compare an asymptomatic aneurysm with a pathology accompanied by the above-described symptoms, the risk of dying from a cardiac aneurysm in the latter case is 5 times higher, and according to some data, even 7 times higher.

Surgical intervention is considered mandatory for saccular and mushroom-shaped forms of aneurysm, which are prone to rupture, while flat aneurysms, which do not pose such a danger, may not be operated on for a long time, although monitoring the dynamics of its development by a cardiologist is mandatory for such patients.

The need for surgical treatment of aneurysm in patients with myocardial infarction is due to high mortality. More than 2/3 of such patients die within the first 3 years, and after 5 years this figure increases by another 20-30%. Surgery to remove a cardiac aneurysm should be performed at least 3 months after the infarction, when dense scar tissue forms at the site of the rupture, which can withstand further manipulations.

Contraindications to surgery may include the patient’s age (over 65 years) or the development of severe heart failure (grade 3).

Types of operations for cardiac aneurysm

Strengthening the walls or removing a cardiac aneurysm with subsequent plastic surgery can be done in various ways. The choice of the type of surgical intervention depends on the type, shape and size of the aneurysm.

In the case of the least dangerous diffuse aneurysms, serious intervention in the structure and function of the heart can be avoided. In this case, the aneurysm wall is often reinforced with various tissues. Such materials can include skin flaps, greater omentum, pectoral muscle, and other types of autotransplants.

Another type of surgical operation - immersion of the aneurysm into the heart with sutures - is effective for small saccular aneurysms that are not prone to thrombus formation. Such an operation helps to eliminate paradoxical pulsation.

Aneurysm immersion can also be performed using a diaphragmatic flap on a stalk with a large vessel running through the center. Such a flap takes root well and after a while grows into the myocardium of the heart with vessels. It is quite strong and does not allow the aneurysm to protrude outward under blood pressure.

Other methods of surgical treatment of cardiac aneurysm are classified as radical interventions that require dissection of the aneurysm located on one of the walls of the heart.

In case of small saccular aneurysms (preferably without parietal thrombi), their removal can be performed using a closed method. The base of the aneurysm is clamped with special clamps, after which the aneurysmal sac is removed.

This was done before, but later the operation was slightly modified. First, they began to dissect the aneurysm tissue and wash out the blood clots inside it with a stream of blood, and then clamp the base of the aneurysm with clamps to resect it. The disadvantage of the operation is the remaining risk of developing arterial thromboembolism.

Open aneurysm removal requires not only opening the chest and heart, but also using a special device that connects to the main blood vessels and provides artificial blood circulation. The operation itself begins only after the blood flow through the heart chambers has completely stopped.

During the operation, the cardiac surgeon has the opportunity not only to remove the aneurysm itself and the parietal thrombi in the heart, but also to assess the condition of the remaining chambers of the heart and its valves, as well as the blood flow in the coronary vessels. If there is a violation of the coronary blood flow, bypass of the vessels is performed in parallel with the resection of the aneurysm.

Open cardiac aneurysm repair can be performed using various methods:

• Linear plastic surgery (the aneurysm is resected after the removal of blood clots and a linear suture in 2 rows is applied at the site of the cut).
• Purse-string plastic surgery (after opening a small aneurysm, a purse-string suture is placed along its edge and tightened).
• Circular patch plasty (a patch made of synthetic material is applied to the site of aneurysm excision).
• Endoventricular patch repair (a patch of sufficient size to preserve ventricular volume is placed inside the aneurysm sac, which is sutured over it).
• Intraventricular balloon plasty.

Which method to use in a given case is decided by the surgeon who performs the operation, taking into account the patient’s condition and postoperative risks.

It would be wrong to say that heart surgery will solve all the problems of patients with cardiac aneurysm. Some complications are possible after surgery. The most common complications include: accumulation of blood in the pericardium, development of heart failure, arrhythmia, and thrombus formation. Cases of death are also possible despite a well-performed surgery.

However, removal of the aneurysm makes drug treatment more effective and gives patients several more years of a decent life.

Folk remedies

Based on the seriousness of the problem and the characteristics of cardiac aneurysm, it becomes clear that folk treatment is unlikely to cause the aneurysm to disappear, which is beyond the power of even drug therapy. However, it can usefully complement drug treatment prescribed for small diffuse aneurysms or in preparation for surgery. It will also be useful for those patients who, due to various circumstances, are forced to be dependent on drugs all their lives.

Here, herbal treatment comes to the forefront, normalizing heart rhythm, blood pressure, and general condition.

Rosehip decoction helps with myocardial weakness (take 1 tbsp of rosehip seeds per 2 cups of boiling water). Add a spoonful of honey to the finished cooled decoction. Take this tasty medicine half an hour before meals 3 times a day, a quarter of a glass.

For tachycardia, an infusion of young asparagus shoots will be useful (3 teaspoons of chopped raw material are poured with a glass of boiling water and infused for 2 hours). The potion should be taken 3 times a day, 2 tablespoons for a month.

An infusion of calendula flowers (2 teaspoons of raw material per 2 cups of boiling water, leave for about an hour) will also help normalize the heart rhythm; it should be taken 4 times a day, half a glass at a time.

Instead of synthetic diuretics that help lower blood pressure, you can use familiar and tasty foods (depending on the season): watermelon, melon, cucumber, pumpkin, beetroot, parsley. In winter, you can use diuretic herbal and plant infusions. But first, you should consult a doctor, since taking synthetic and natural diuretics at the same time can lead to dehydration.

Traditional healers use herbs such as mountain arnica, marsh cudweed, motherwort, lemon balm, and Baikal stachys as herbal beta-blockers.

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Homeopathy

Homeopathy for cardiac aneurysm is also indicated as an adjunct to drug treatment, which means that the possibilities of its use should be discussed with the attending physician. Homeopathic treatment helps relieve unwanted symptoms and prevent some complications of the disease, but it is not able to get rid of the aneurysm itself.

Ultimately, homeopathic treatment, like traditional conservative treatment, can end with plastic surgery or aneurysm removal. But on the other hand, a person with limited capabilities in terms of surgical intervention also has the right to feasible help, which homeopathy can provide. Thanks to it, the patient can safely and reliably normalize the heart rhythm, cope with high blood pressure and prevent the formation of blood clots.

The most popular homeopathic medicine of this kind is Arnica, which acts both as a thrombolytic and a beta-blocker.

Additionally, depending on the situation and constitutional features of the patient, the following drugs may be prescribed: Calcarea fluorica, Carbo vegetabilis, Arsenicum album, Gloninum, Iodum, Ignatia, Natrium muriaticum, Rhus toxicodendron, Crategus, etc.

The selection of drugs, as well as the appointment of an effective and safe dosage, should be entrusted to an experienced homeopathic doctor and it is imperative to discuss the possibilities of their use with your doctor.