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257

Diverticulosis

of the

Left

Ventricle

Harold William

A. Baltaxe,1 J. Wilson,2 and M AmieI3 .

Nine patients, 4-60 years old, had single or multiple left ventricular outpouchings, best seen during diastole, and believed to represent congenital diverticula. The 14 diverticula, 5-28 mm long, were either along the diaphragmatic or anterior ventricular

wall. Only one patient had his diverticulum surgically removed; the wall was lined by thick endocardium surrounded by normal myocardium. The lesions did not produce local or systemic complications. All patients had normal chest radiographs. The material suggests that left ventricular diverticula not associated with midline anomalies are perhaps not very rare and should be distinguished from cardiac aneurysm.

A saccular henniation

the

deformity

left

of the

a partial

through

ventricle

are

left

usually

aneurysm’

diverticula

described

by various

authors

‘

the left ventricle, 1 3 cases [9]. Diverticula may or may aneurysm.

.

Received revision

December

April

23,

29,

1 978;

accepted

after

1979.

Department of Radiology, University of Nebraska Medical Center, 42d and Dewey Ave. , Omaha, NB 681 05. Address reprint requests to H. A. Baltaxe. 2

Long

Beach

Memorial

Hospital,

Long

Beach,

but not

aneurysms

in native

from

Such more

diverticula frequent

Subjects

and

the

apex

thinned

associated

do not result than previously

aneurysm,

a localized Diverticula

Several

has

diverticula

types

been

Africans,

have

myocardium

layers

intact.

diverticula with

in complications, believed.

may

‘

reported

intermingled The wall

wall

congenital

the apex

of

in only

wall of an aneurysm it is a true or a false

of the

thoracic

been

with midline type of left

from

been

of

have

called

arising

from aneurysms. The depending on whether

contain

nor

Africans

in native

tissue whereas diverticula have all their is usually only formed by pericardium. Nine patients with single on multiple arising

an

been reported associated masses [1 -6]. A specific

[7, 8]. Isolated

occurring

be

or a diverticulum.

to be congenital.

have pulsatile

must be distinguished not contain myocardium True

may

defect,

thought

described. Congenital diverticula thoracoabdominal defects and ventricular

ventricle

penicardial

with

of a false left

defects

be multiple,

ventricle are and

fibrous

aneurysm neither described.

are

possibly

Methods

CA 90801. 3

Lyon, AJR

H#{244}pitalCardio-Vasculaire

et Pneumologique,

France. 133:257-261,

0361 -803X/79/1332-0257 © American Roentgen

Nine University

August Ray

1979 $00.00 Society

patients

with

of Nebraska

left

ventricular

Medical

California, H#{244}pitalCardio-Vasculaire italier Regional de Nantes, France. about 3,400 left ventniculograms.

diverticula

Center,

Memorial

were

collected

Hospital

Medical

over

a 3 year Center

period

of Long

from Beach,

et Pneumologique of Lyon, France, and Centre HopDuring that time these institutions collectively performed The patients were six adults, 26-60 years old, and three

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258

BALTAXE

ET AL.

AJR:133,

August

1979

3

9 Fig.

1 -Direct

tracings

from

ative left ventriculograms 1 ) with cardiac diverticula

children,

4-6

cine

frames

in diastole

of represent-

of patients

1 -9 (table

(arrows).

years

old.

There

were

six

male

patients

and

three

female.

All patients underwent a total workup that included chest radiography, 1 2 lead electrocardiography, and cardiac catheterization consisting had

of a complete

a left

physiologic

selective

coronary

culograms

angiography;

in the

patients

were

and

palpitation.

heart

lesions,

The mild

three

diastole

one

totally

ulography

was None

ventricular

septal

several

not

defects

cardiac

had

or pulsatile

had

mild

patient

During

had

epigastnic

bled. was

hemoleft

yen-

visible

during

Right

ventnic-

a

had

two

the

mitral

case

did

the

of the mitral and its cavity (fig.

2, table

they (fig.

did 3).

not

ring lesion

diverticula

each,

thonacoab-

whereas

in the four others for lesions were either along

(fig.

valve. The was about 1 ). All totally

All

arteries

tion

the

largest 28 mm

2 and

and

a large

was

lined

muscle

layer

around

the

to and

diverticulum

chest

radiographs.

angiographic

results

Clinical, are

elec-

summarized

i.

general

a single

3),

but

in neither

ular

types

recognized et al. [2]

been

anomalies of ectopia with

but cases

main complaint was contractions demon-

a ventral

hernia,

of the nine associated

had

(fig.

2).

normal Excision

in the histologic

by a thickened

coronary of the

number of examina-

endocardium

patients reported with these various

mm [5]. In the second

It occurs

and

and

type,

the

left

intimately

related

in Nigerians,

South

American

Negro

as fibrous

congenital

also occur in the such a ‘cystlike

[7,

8]. These diverticula

left

rather usually

defect, various commonly

are

generally

and aortic Bantu, Indians, have

apical or subvalvular diverticulum’ ‘ of

left

at

than

diverticula

of the

the the

those

of the diverticula were about 30x

mitral

lesions

of

cardiac

located larger

ventricular African

than a type associated

a defect

here. Most anomalies

to the

cardiac have these

associated

are

by

ventric-

of a syndrome of So far, 46 instances It has been suggested

and

diverticula

have

described

congenital

a sternal

the diaphragm,

of the

valvular

first,

constitute a distinct syndrome cordis [4]. The diverticula are

The

systole,

diverticula

The

comprises

diverticula that are part and midline defects. reported in the world [9].

left ventricle

in three

ventricular

anomalies

apex

during

left

literature.

in 1 958,

anomalies.

end-systole

of

in the

diverticulum was resected long and 1 0 mm in diameter

was followed by reduction ventricular contractions. On diverticulum

diverticulum

of hemosiderin. According the area had been injured

normal

penicardium,

She

diverticulum

Large

amounts implied

and

or prolapse

woman whose premature

electrocardiography.

projection.

ventricle.

Discussion

a total of 14 the diaphrag-

regurgitation

contracted during

had

patients

in table

25

by

diverticulum premature

mitral

lesions efface

Case 3, a 51 -year-old palpitation , had numerous strated

1 , cases

produce

oblique of left

masses.

matic wall [1 0] or along the midportion of the anterior wall [3] (fig. 1 ). Of those along the diaphragmatic wall, two were near

the

trocardiographic,

Cantrell occurred These

part

diverticulum

midline

Findings patients

anterior

large this

However,

Three

Five

right

normal.

been

diverticulum outpouchings.

3.

diaphragmatic

that contained the pathologist,

congenital and

systole.

associated

adult

tachycardia

stenosis,

during

One

patients

for

defect.

ventni-

Four

two

outpouchings

contracted

performed.

of the

patients subaortic

and

had

projections. and

stenosis,

or partially

resected. dominal

or

pain

2.-Case along

patients

projection

patients

lateral

chest

pediatric

aontic

All adult

oblique

pediatric

and for

insignificant

tniculography

anterior

the

anteropostenior

investigated

dynamically

assessment.

in the right

ventniculogram

Fig. (arrow)

been ventricle

is subvalves. and the classified and

can

position. Rupture of the left ventricle was

AJR:133,

August

TABLE

DIVERTICULA

1979

i : Left Ventricular

case

Age (years)

No.

gender

chef

60, M

1

complaint

.

Angina

Ventricular

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3

Chest

Si , F

pain

Palpitations

(mm)

tachycar-

night

branch 50, M

VENTRICLE

Diverticula

.

Efectrocardiogram

dia;

2

LEFT

259

Diverticula .

.

OF

Location .

from

Diaphragm

bundle

15 x

block

and Size

.

surface,

Diaphragm

Multiple premature ventricular contrac-

close to mitral lOx 8 1 0 x 8 Diaphragm surface, close

mitral

Therapy

left

coronary

Coronary

ring,

coronary

bypass

an-

tery; 90% stenosis, obtuse marginal 95% stenosis, night

surface,

ring,

Angiography

stenosis,

main

12 x 8

Normal

tions

90%

1 0; anterior

wall,

.

coronary

duverticulogram

None

artery

Normal

Excision lum

to

of diyerticu-

28 x 10

4

Si , M

Angina

Normal

Diaphragm surface, 1 5 x 1 5, 8 x 8

1 0%-20% stenosis, left anterior descending night cononary artery

Medical

5

26, M

Angina

None

50, M

Tachycardia (i 30 beats! mm)

Diaphragm surface, 12 x 9, 9 x 6 Diaphragm surface, 9 x 9; anterior wall,

Normal

6

ST-T elevation in Ieads2-3and aVF Sinus tachycandia

Normal

None

7

6, F

Heart murmur (grade l,’VI

Not done

Mild aortic

8

4, F

9

1 4, M

10x8 Diaphragm x 5

Normal

systolic) Heart murmur

surface,

S

mm

Leftventnicularhypertrophy

Diaphragm surface, x 5, 5 x 3

Normal

Anterior

5

stenosis

gradient;

9

no

Not done

therapy Surgery for removal of subaortic mem-

Normal

Small

brane

Chest

pain (2

episodes); systolic mun Note

-All

Fig.

reported African diverticula

rysms. are

patients

we re white,

3.-Case

1

.

by Drennan girl

who

are Chesler

probably

died

and

for

right

Van

suddenly.

no.

to congenital

ventricular

tal defects; apy needed

3, who

anterior

was

oblique

derVijver Since

sepno then-

black.

projection.

Two

diverticula

the

walls

epicardial

cysts.

of these as aneudiverticula

B, Systole:

(arrows).

[1 1 ] in a 4-year-old

fibrous, they are usually classified et al. [8] believe that these fibrous related

8 x 6

mur-

except

A, Diastole:

wall,

The

third

1 3 isolated

type

diverticula

was

diverticula

described of the apex

midline

thoracic

the

and four of these et al. [9] also imply that

literature

Hoeffel

wall

contracted,

abnormalities

but still appear

by Hoeffel

(arrows).

et al. [9].

of the left ventricle have

been

To date, without

described

have undergone operation. another rare type of diver-

in

BALTAXE

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260

Fig. 4.-Case effacement

8. A, Diastole:

of both

ticulum

can

coronary

diverticula

be

been reported. The lesions the

due

artery,

above

to

but

an

nine

types,

mains rysms

deep

were

The lesions types

they

no racial

of

such

although

considered

surgical

On the

case,

they

described thickened thickened

be

with

the

of an acquired only

perfusion

with

scans pattern or

process,

young but

significance

B, Systole:

total

in

structure

anomalies.

emboli. because

associated

differs

from

with

the cases

fibrotic

emboli. The the lack of

lesions are enveloped

[1 1 ]. Conceivably

derVijver

the

systemic may explain

Furthermore the they are probably

which Van

intramural time

mistake ventricular mal

to

been

none ever manifested size of these lesions

previously been in the pathologic the

single

and

have

unlikely to by normal

reported

by Dren-

if the

diverticula

were located close to the mitral ring, mitral incompetence might occur; this was not observed in our patients. The multiplicity of the left ventricular diverticula has

of

reported literature. location,

and

their description This may be due

and

pathologic

to the

examination.

arteries

abnormal

[1 2],

contracting

but

postmortem

changes

It is essential

they

can

be

not

is not found to their size,

these diverticula for aneurysms. Occasionally, aneurysms can be seen in the presence

coronary

their

at

not

to

left of nor-

identified

by

for supplying

case

pattern.

This

the

diverticulum

were believe patients admittedly

not that

as and 3.

lessens

a

ACKNOWLEDGMENTS

We thank

a fibrous

of these

are the

the congenital

lesions

Professors

H. Petitier

and Hoeffel

6.

observed they

having

also

by

us

in

congenital. possibility nature

REFERENCES 1

be surmised.

The clinical

(arrows).

surface

of Souli#{233}et al. [1 0] who

a thick muscular layer, layer similarly to case

in very

location by our

a similar

midline

previous anomalies,

no constant

as suggested

various of

other

patients, small

systemic rupture nan

in

hypokinetic

of our relative

emboli

myocardium,

typical

present

from the three

to have

the

4, we

diaphragmatric

aneurysms of the left ventricle described in the Bantu. Chesler et al. [8] reported two cases with systemic emboli originating from fibrous diverticula. In reviewing the histories

from

and

were

to the

had

hand,

diverticula

along

Systemic

diverticula

contraction

associated

observations

age

diverticula

1979

left

their

and

structure

these under

presence

not

other

Two

August

has

proof. Aneuin that they

precordium

dissimilar

appeared

serosa, internal

Although patients

the

here differed

with

consistent

the case

different to

the systolic

quite

were

associated

was

over

predilection,

ventricle.

projection.

of aneurysms.

reported

in that

those

was

behavior

oblique

during systole and were best seen As already noted by others [1 ], the of the ventricle is difficult and re-

Furthermore,

lesions

dyskinetic

can

patients,

Q waves

not done.

of these

Their

origin no

perfusion scans. No Q waves nine patients and myocardial

myocardial any of our

the

anterior

in question in the absence of histologic may be distinguished from diverticula

produce

had

anomalous knowledge

are

because they contracted during diastole (fig. 4). diagnosis of diverticula

in right

AJR:133,

systole.

to our

in our three

left ventriculogram during

ET AL.

is questionable.

2.

.

Bandow GT, Rowe GG, Crummy AB: Congenital of the right and left ventricles. Radiology 117 Cantrell JA, Hailer JA, Aavitch MM: A syndrome

diventiculum :1

9-20,

197

of congenital

AJR:133,

August

defects

involving

the

and

heart.

penicardium

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DIVERTICULA

1979

abdominal Surg

wall,

Gynecol

sternum, Obstet

OF LEFT

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375,

Diverticulum 119-123,

7.

Dubb

415,

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A, Katz G, Benk M: Left ventricular

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