Giant Postischemic Left Ventricular Aneurysm Without Q Waves

BACKGROUND: Left ventricular aneurysm (LVA) is a mechanical complication of myocardial infarction, typically associated with anterior infarction and diagnostic electrocardiographic changes. However, nonanterior aneurysms may present with misleading findings, delaying diagnosis. CASE SUMMARY: A 55-year-old woman with inferolateral myocardial infarction underwent successful percutaneous coronary intervention. Despite enzymatic evidence of necrosis, serial electrocardiograms showed no pathological Q waves. Multimodality imaging revealed progressive left ventricular remodeling with aneurysmal evolution and mural thrombus formation. Echocardiography documented transition from regional dysfunction to aneurysm, while cardiac magnetic resonance confirmed transmural fibrosis and excluded viability and pseudoaneurysm. Surgery was initially deferred but was later expedited owing to thrombus progression. Ventricular reconstruction with aneurysm exclusion and mitral annuloplasty was successfully performed. CONCLUSIONS: LVAs may develop without pathological Q waves. Multimodality imaging is essential for diagnosis, tissue characterization, and surgical decision-making. TAKE-HOME MESSAGES: LVA may develop without pathological Q waves, particularly in nonanterior myocardial infarctions, potentially delaying diagnosis. Serial multimodality imaging is essential to identify aneurysm progression, detect mural thrombosis, and guide individualized timing of surgical intervention.