Management of Left Ventricular Apical Aneurysm in Hypertrophic Cardiomyopathy

Initial Medical Management

• The European Society of Cardiology recommends starting high-dose beta-blockers as first-line therapy for symptomatic patients with LV apical aneurysms, though response is often suboptimal in this population 1
• Alternative options include verapamil or diltiazem if beta-blockers are not tolerated, aiming to reduce LV diastolic pressures and improve filling by slowing heart rate, ideally monitored by ambulatory ECG 1

Anticoagulation Strategy

• Long-term oral anticoagulation is mandatory when thrombus is present within the aneurysm, and warfarin remains the standard anticoagulant for this indication 1

Risk Stratification for Sudden Cardiac Death

• ICD implantation should be strongly considered based on the high arrhythmic risk, even in the absence of traditional SCD risk factors, with a 4.7%/year sudden death event rate 1

Management of Ventricular Arrhythmias

• Recurrent monomorphic VT related to apical scarring may be amenable to catheter ablation, and mapping and ablation should be considered for patients with frequent appropriate ICD therapies 1

Surgical Considerations

• Surgery can be performed via transaortic myectomy, transapical approach, or combined incisions with good short-term outcomes 1

Monitoring and Follow-Up

• Serial imaging is essential to monitor for aneurysm growth, thrombus formation, and development of complications 1