Catheterization and Cardiovascular Diagnosis 26:31-33 (1992)
Left Ventricular Diverticulum: Case Report and Review of the Literature Melissa Walton-Shirley, MD, Steven M. Smith, MD, and J. David Talley,
MD
We describe two patients with left ventricular diverticula which were seen during routine left ventriculography. The diverticula were probably incidental findings and asymptomatic. A review of the literature to determine associated cardiac and extra-cardiac abnormalitles and related morbidity and mortality with emphasis of potential treatment strategies is presented. o 1x12wiiey-~isr,tnc. Key words: ventriculography, diverticulum, congenital abnormality
INTRODUCTION
Left ventricular diverticulum (LVD) is a rare finding in the adult population and was reported in only 0.4% of 750 cardiac necropsies [ 11. The majority of LVD arise from the apex of the left ventricle and are usually found in children [2]. They have been documented in approximately 80 patients, however, only six have been reported in adults [2,5]. In 70% of patients with LVD there are associated midline thoroco abdominal defects or other congenital cardiac malformations [5]. Associated congenital abnormalities include ventricular septal defect with or without pulmonic stenosis, atrial septal defect and dextrocardia, endocardia1 cushion defects, persistent truncus arteriosus, tricuspid atresia, and anomalous pulmonary or systemic venous return [3]. In the remaining 30%, the LVD is associated with no other cardiac malformations, are asymptomatic, and incidently discovered on radiographic examination or echocardiogram [ 21. We present two adult males with LVD detected during left ventriculography not associated with other anomalies. The finding was probably incidental. PATIENT 1 A 58-yr-old black male presented with prolonged chest discomfort suggestive of myocardial ischemia and syncope. There was a long history of heavy ethanol use. The cardiovascular examination was normal. There was no evidence of myocardial necrosis by analysis of serum isoenzymes and electrocardiography. Late potentials were detected on signal average electrocardiography. At cardiac catheterization there was total occlusion of the proximal right coronary artery with collateralization from the distal circumflex artery. There were no other anatomically significant lesions. Left ventriculography revealed a small, finger-like projection protruding from 0 1992 Wiley-Liss, Inc.
the mid-diaphragmatic wall. With the catheter as standard, the LVD measured 1.9 mm wide and 4.4 mm long during diastole (Fig. 1) and 2.5 mm wide and 5.5 mm long in systole (Fig. 2). There was severe hypokinesis of the posterior basal, and apical segments and the calculated left ventricular ejection fraction was 28%. There were no sustained ventricular dysarrhythmias detected by 24 hr electrophysiological monitoring or inducability testing. There was a normal response to passive head-up tilt table testing. Medical management was prescribed for the coronary heart disease and the etiology of the syncopy was not identified. PATIENT 2
A 48-hr-old white male was admitted with new onset chest discomfort at rest. The cardiovascular examination was normal. There was no evidence of myocardial necrosis by analysis of serum isoenzymes and electrocardiography. A transthoracic echocardiogram revealed normal right and left ventricular sizes, shapes, and function. An exercise test with thallium was positive for ischemia in the inferior and anterior lateral walls at a double product of 35,696. There was no anatomical significant lesions seen on coronary arteriography. Multiple middiaphragmatic LVD were seen in diastole (Fig. 3). There was systolic compression of the smaller LVD, with only
From the Section of lnterventional Cardiology, Cardiovascular Division, Department of internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky. Received May 3 I . 1991; revision accepted October I , I99 I . Address reprint requests to J . David Talley. MD, Chief, lnterventional Cardiology, Cardiovascular Division, Ambulatory Care Building, 530 South Jackson Street, Louisville, KY 40202.
32
Walton-Shirley et al.
Fig. 1. The left ventricular diverticulum (1.9 nm (with) x 4.4 mm (length)] is seen in the mid diaphragmatic wall during diastole.
Fig. 3. Multiple left ventricular diverticula are seen in the mid diaphragmatic wall in diastole. They measure(from left to right): 1.7 mm, 1.5 mm, and 4.3 mm, respectively, in width and 3.7 mm, 3.2 mm, and 4.4 mm in length.
Fig. 2. During systole the left ventricular diverticulum measured 2.5 mm in width x 5.5 mm in length.
Fig. 4. There is systolic compression of the multiple diverticula, only the largest of which remains angiographically visible (1.7 mm in width and 4.2 mm in length).
the largest remaining angiographically visible during systole (Fig. 4). Non-cardiac etiologies of chest discomfort were to be evaluated post-discharge.
Congestive heart failure is reported to be the leading cause of death [ 5 ] . Other complications inclusive of peripheral embolism, chest pain syndrome, sudden cardiac death and endocarditis have been reported (2-4,7]. The DISCUSSION case of a 6-year-old male who died suddenly while playVarious diagnostic techniques to detect LVD, includ- ing has been reported with autopsy confirmation of a ing echocardiography , radiography, and MRI. have been ruptured LVD as the cause of death [ 5 ] . The etiology of ventricular diverticulum is unknown. reported [ 1,7]; however, patients with a small LVD may have normal studies. Cardiac catheterization and angiog- There has only been one report of familial occurrence raphy appear to be the only reliable and conclusive pro- involving siblings [6]. The LVD noted in these patients located on the left cedure for detecting LVD and its associated cardiac lesions and for determining the need for corrective ventricular diaphragmatic surface and not associated with cardiac or extra-cardiac abnormalities has been presurgery. The morbidity and mortality associated with LVD var- viously described by Baltaxe et al. [8]. In that report, the ies. Patients with a large diverticulum have undergone LVD were multiple and located on the anterior wall [8]. successful surgical resection in order to prevent the com- They too, were clinically silent, discovered incidentally, plications of acute rupture and cardiac tamponade [2]. and required no intervention [8].
Left Ventricular Diverticulum
We believe the chest pain syndrome described in our patients are possibly unrelated to the small LVD detected however, the correlation with the exercise thallium defects in the inferior wall in patient 2 remain undefined. ACKNOWLEDGMENTS The authors wish to thank Sharon McGregor for her expert secretarial support in the preparation of this manuscript, Tracy Crum for angiographic analysis, and Dr. Marcus Stoddard for echocardiographic interpretation. REFERENCES I . Mardini MK: Congenital diverticulum of the left ventricle: Report of two unusual cases. Br Heart J 51:321-326, 1984.
33
2. Sillen C. Beat F, Rutishauser W: Congenital intrathoracic left ventricular diverticulum in an adult. Chest 98:750-751, 1990. 3. Nicod P, Laird WP, Firth BG, Nicod L, Fixler D: Congenital diverticula of the left and right ventricles: Three cases. Am J Cardiol 53:342-344, 1984. 4 . Calderon J , Azuara H, Osoanio A, del Consuelo Calleja M. Bwendia A, Attie F: Congenital ventricular diverticula: Presentation of 6 cases. Arch Inst Cardiol Mex 59:383-388, 1989. 5 . Gowitt GT. Zaki SA: Rupture of a cardiac diverticulum resulting in sudden death. Am J Forensic Med Pathol 9:155-158. 1988. 6. Shizukuda Y, Murakami H, lwakura M , Hashimoto A. Tsuchihashi K , Yonekura S, Tanaka S, Shimamoto K, Sat0 M , limura 0: Siblings with left ventricular diverticulum and hypertrophic cardiomyopathy. J Cardiol (Japan), 18:867-874, 1988. 7 . Handler CE, Walker JM: Congenital diverticulum of the left ventricle presenting as heart failure and diagnosed by MRI. Int J Cardiol 22:115-119, 1989. 8. Baltaxe HA. Wilson WJ. Amiel M: Diverticulosis of the left ventricle. Am J Roentgenol 133:257-261. 1979.
Left Ventricular Diverticulum: Case Report and Review of the Literature Melissa Walton-Shirley, MD, Steven M. Smith, MD, and J. David Talley,
MD
We describe two patients with left ventricular diverticula which were seen during routine left ventriculography. The diverticula were probably incidental findings and asymptomatic. A review of the literature to determine associated cardiac and extra-cardiac abnormalitles and related morbidity and mortality with emphasis of potential treatment strategies is presented. o 1x12wiiey-~isr,tnc. Key words: ventriculography, diverticulum, congenital abnormality
INTRODUCTION
Left ventricular diverticulum (LVD) is a rare finding in the adult population and was reported in only 0.4% of 750 cardiac necropsies [ 11. The majority of LVD arise from the apex of the left ventricle and are usually found in children [2]. They have been documented in approximately 80 patients, however, only six have been reported in adults [2,5]. In 70% of patients with LVD there are associated midline thoroco abdominal defects or other congenital cardiac malformations [5]. Associated congenital abnormalities include ventricular septal defect with or without pulmonic stenosis, atrial septal defect and dextrocardia, endocardia1 cushion defects, persistent truncus arteriosus, tricuspid atresia, and anomalous pulmonary or systemic venous return [3]. In the remaining 30%, the LVD is associated with no other cardiac malformations, are asymptomatic, and incidently discovered on radiographic examination or echocardiogram [ 21. We present two adult males with LVD detected during left ventriculography not associated with other anomalies. The finding was probably incidental. PATIENT 1 A 58-yr-old black male presented with prolonged chest discomfort suggestive of myocardial ischemia and syncope. There was a long history of heavy ethanol use. The cardiovascular examination was normal. There was no evidence of myocardial necrosis by analysis of serum isoenzymes and electrocardiography. Late potentials were detected on signal average electrocardiography. At cardiac catheterization there was total occlusion of the proximal right coronary artery with collateralization from the distal circumflex artery. There were no other anatomically significant lesions. Left ventriculography revealed a small, finger-like projection protruding from 0 1992 Wiley-Liss, Inc.
the mid-diaphragmatic wall. With the catheter as standard, the LVD measured 1.9 mm wide and 4.4 mm long during diastole (Fig. 1) and 2.5 mm wide and 5.5 mm long in systole (Fig. 2). There was severe hypokinesis of the posterior basal, and apical segments and the calculated left ventricular ejection fraction was 28%. There were no sustained ventricular dysarrhythmias detected by 24 hr electrophysiological monitoring or inducability testing. There was a normal response to passive head-up tilt table testing. Medical management was prescribed for the coronary heart disease and the etiology of the syncopy was not identified. PATIENT 2
A 48-hr-old white male was admitted with new onset chest discomfort at rest. The cardiovascular examination was normal. There was no evidence of myocardial necrosis by analysis of serum isoenzymes and electrocardiography. A transthoracic echocardiogram revealed normal right and left ventricular sizes, shapes, and function. An exercise test with thallium was positive for ischemia in the inferior and anterior lateral walls at a double product of 35,696. There was no anatomical significant lesions seen on coronary arteriography. Multiple middiaphragmatic LVD were seen in diastole (Fig. 3). There was systolic compression of the smaller LVD, with only
From the Section of lnterventional Cardiology, Cardiovascular Division, Department of internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky. Received May 3 I . 1991; revision accepted October I , I99 I . Address reprint requests to J . David Talley. MD, Chief, lnterventional Cardiology, Cardiovascular Division, Ambulatory Care Building, 530 South Jackson Street, Louisville, KY 40202.
32
Walton-Shirley et al.
Fig. 1. The left ventricular diverticulum (1.9 nm (with) x 4.4 mm (length)] is seen in the mid diaphragmatic wall during diastole.
Fig. 3. Multiple left ventricular diverticula are seen in the mid diaphragmatic wall in diastole. They measure(from left to right): 1.7 mm, 1.5 mm, and 4.3 mm, respectively, in width and 3.7 mm, 3.2 mm, and 4.4 mm in length.
Fig. 2. During systole the left ventricular diverticulum measured 2.5 mm in width x 5.5 mm in length.
Fig. 4. There is systolic compression of the multiple diverticula, only the largest of which remains angiographically visible (1.7 mm in width and 4.2 mm in length).
the largest remaining angiographically visible during systole (Fig. 4). Non-cardiac etiologies of chest discomfort were to be evaluated post-discharge.
Congestive heart failure is reported to be the leading cause of death [ 5 ] . Other complications inclusive of peripheral embolism, chest pain syndrome, sudden cardiac death and endocarditis have been reported (2-4,7]. The DISCUSSION case of a 6-year-old male who died suddenly while playVarious diagnostic techniques to detect LVD, includ- ing has been reported with autopsy confirmation of a ing echocardiography , radiography, and MRI. have been ruptured LVD as the cause of death [ 5 ] . The etiology of ventricular diverticulum is unknown. reported [ 1,7]; however, patients with a small LVD may have normal studies. Cardiac catheterization and angiog- There has only been one report of familial occurrence raphy appear to be the only reliable and conclusive pro- involving siblings [6]. The LVD noted in these patients located on the left cedure for detecting LVD and its associated cardiac lesions and for determining the need for corrective ventricular diaphragmatic surface and not associated with cardiac or extra-cardiac abnormalities has been presurgery. The morbidity and mortality associated with LVD var- viously described by Baltaxe et al. [8]. In that report, the ies. Patients with a large diverticulum have undergone LVD were multiple and located on the anterior wall [8]. successful surgical resection in order to prevent the com- They too, were clinically silent, discovered incidentally, plications of acute rupture and cardiac tamponade [2]. and required no intervention [8].
Left Ventricular Diverticulum
We believe the chest pain syndrome described in our patients are possibly unrelated to the small LVD detected however, the correlation with the exercise thallium defects in the inferior wall in patient 2 remain undefined. ACKNOWLEDGMENTS The authors wish to thank Sharon McGregor for her expert secretarial support in the preparation of this manuscript, Tracy Crum for angiographic analysis, and Dr. Marcus Stoddard for echocardiographic interpretation. REFERENCES I . Mardini MK: Congenital diverticulum of the left ventricle: Report of two unusual cases. Br Heart J 51:321-326, 1984.
33
2. Sillen C. Beat F, Rutishauser W: Congenital intrathoracic left ventricular diverticulum in an adult. Chest 98:750-751, 1990. 3. Nicod P, Laird WP, Firth BG, Nicod L, Fixler D: Congenital diverticula of the left and right ventricles: Three cases. Am J Cardiol 53:342-344, 1984. 4 . Calderon J , Azuara H, Osoanio A, del Consuelo Calleja M. Bwendia A, Attie F: Congenital ventricular diverticula: Presentation of 6 cases. Arch Inst Cardiol Mex 59:383-388, 1989. 5 . Gowitt GT. Zaki SA: Rupture of a cardiac diverticulum resulting in sudden death. Am J Forensic Med Pathol 9:155-158. 1988. 6. Shizukuda Y, Murakami H, lwakura M , Hashimoto A. Tsuchihashi K , Yonekura S, Tanaka S, Shimamoto K, Sat0 M , limura 0: Siblings with left ventricular diverticulum and hypertrophic cardiomyopathy. J Cardiol (Japan), 18:867-874, 1988. 7 . Handler CE, Walker JM: Congenital diverticulum of the left ventricle presenting as heart failure and diagnosed by MRI. Int J Cardiol 22:115-119, 1989. 8. Baltaxe HA. Wilson WJ. Amiel M: Diverticulosis of the left ventricle. Am J Roentgenol 133:257-261. 1979.
