Rapidly Progressive Post-Infarction Left Ventricular Aneurysm: Multimodality Imaging-Guided Assessment of Adverse Remodeling and Surgical Ventricular Restoration.

Background: Rapid, disproportionate expansion of post-infarction left ventricular (LV) aneurysms represents a high-risk remodeling phenotype characterized by progressive mechanical deterioration and severe geometric distortion. Methods: A 54-year-old male presented with late anterior myocardial infarction complicated by a partially thrombosed apical LV aneurysm with an initial left ventricular ejection fraction (LVEF) of 35%. Despite clinical stability under optimal guideline-directed medical therapy, serial multimodality imaging at 7 weeks revealed an aggressive, disproportionate expansion of the aneurysmal component to 120 mL, inducing severe ventricular geometric distortion and secondary functional degradation (LVEF 20%). Multimodality imaging demonstrated a favorable geometry of the functional ventricle with preserved contractile function. Results: The patient underwent prompt surgical ventricular restoration using a double-patch Dor technique, effectively excluding the large aneurysm and restoring physiological ventricular geometry. The postoperative course was uneventful. At 6-month follow-up, cardiovascular magnetic resonance confirmed sustained reverse remodeling and significant recovery of systolic LV function (LVEF 47%). Conclusions: This case illustrates that rapid post-infarction aneurysmal expansion may occur despite apparent clinical stability. Comprehensive multimodality imaging may help identify selected patients in whom a reconstructible myocardial substrate supports surgical ventricular restoration despite severely reduced LVEF, even when conventional clinical indications for aneurysmectomy are absent.