Congenital left ventricular diverticulum: Multimodality imaging evaluation and literature review

A Rare Case of Congenital Left Ventricular Diverticulum With Apical Thrombus: Diagnostic Challenges and Management Insights

A myocardial diverticulum is a rare congenital anomaly characterized by pouch-like protrusions within the myocardial wall, which can potentially lead to various cardiac complications. This case report describes a unique presentation of a left ventricular diverticulum (LVD) with an associated apical thrombus, highlighting the diagnostic and management challenges posed by this condition. A 58-year-old man presented to the emergency department with left arm weakness, wrist drop, and chest pain, initially raising concerns for a stroke. Diagnostic evaluations, including echocardiography and magnetic resonance imaging (MRI), revealed a small focal outpouching at the left ventricular apex, consistent with a congenital LVD containing a thrombus. This diagnosis was supported by the patient's historical imaging dating back to 2007, which had similarly identified this outpouching. The patient was managed with anticoagulation therapy, transitioning from heparin to warfarin, alongside standard cardiac care. This case underscores the importance of considering myocardial diverticulum in the differential diagnosis of patients presenting with cardiac symptoms that might initially suggest more common conditions, such as stroke. It also highlights the essential role of echocardiography and MRI in diagnosing and managing myocardial diverticula.

Society for Cardiovascular Magnetic Resonance 2022 Cases of SCMR case series

"Cases of SCMR" is a case series on the SCMR website (https://www.scmr.org) for the purpose of education. The cases reflect the clinical presentation, and the use of cardiovascular magnetic resonance (CMR) in the diagnosis and management of cardiovascular disease. The 2022 digital collection of cases are presented in this manuscript.

Dilated left ventricle with multiple outpouchings — a severe congenital ventricular diverticulum or left-dominant arrhythmogenic cardiomyopathy: A case report

BACKGROUND

Left-dominant arrhythmogenic cardiomyopathy (LDAC) is a relatively rare disease characterized by poor prognosis that exacerbates the incidence of sudden cardiac death and ventricular arrhythmias. Clinically, LDAC is constantly overlooked or misdiagnosed as myocardial infarction, myocarditis, and dilated cardiomyopathy, owing to atypical and nonspecific clinical manifestations at an early stage.

CASE SUMMARY

A 57-year-old woman was diagnosed with sinus bradycardia and chronic bifascicular block during a health check. She occasionally experienced mild chest pain and paroxysmal palpitation during activity in the past 2 years. Comprehensive auxiliary examinations, including electrocardiogram, echocardiography, coronary computerized tomography angiography, and magnetic resonance imaging, revealed that she had LDAC instead of congenital ventricular diverticulum. The physicians prescribed standard oral therapy for heart failure and implantable cardioverter-defibrillator. Consequently, her left ventricular systolic function and symptoms remained stable at the 2-year follow-up after discharge.

CONCLUSION

Based on this case, clinicians need to be aware of LDAC in patients with localized left ventricular lesions and multiple electrocardiographic abnormalities. Multimodality cardiovascular imaging is effective in identification of multiple types of cardiomyopathy and cardiac inner structures.

[Ventricular diverticulum in Cantrell´s pentalogy: rare but not isolated entities]

Pentalogy of Cantrell is a rare entity characterized by a combination of alterations, among which the following stand out: defects of the pericardium, heart, diaphragm, lower third of sternum and abdominal wall. On the other hand, congenital cardiac diverticulum is a rare malformation whose presentation is associated with Cantrell's pentalogy in some cases. We present the case of a child with Cantrell's pentalogy who, during follow-up, was diagnosed with left ventricular diverticulum, which required surgical management with a favorable outcome. Addressing these conditions requires the use of cardiovascular images that allow timely decision-making by the treating team.

Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Background and Aims

Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making.

Methods

The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated.

Results

Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes.

Conclusions

Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

Assessment of Left Ventricular Myocardial Diseases with Cardiac Computed Tomography

Rapid advances in cardiac computed tomography (CT) have enabled the characterization of left ventricular (LV) myocardial diseases based on LV anatomical morphology, function, density, and enhancement pattern. Global LV function and regional wall motion can be evaluated using multi-phasic cine CT images. CT myocardial perfusion imaging facilitates the identification of hemodynamically significant coronary artery disease. CT delayed-enhancement imaging is used to detect myocardial scar in myocardial infarction and to measure the extracellular volume fraction in non-ischemic cardiomyopathy. Multi-energy cardiac CT allows the mapping of iodine distribution in the myocardium. This review summarizes the current techniques of cardiac CT for LV myocardial assessment, highlights the key findings in various myocardial diseases, and presents future applications to complement echocardiography and cardiovascular magnetic resonance.

Multiple Congenital Heart Abnormalities

Congenital heart abnormalities are rare and most often occur separately. These structural and functional disorders can cause a range of diseases that vary in severity, from mild or even asymptomatic to severe and life-threatening. Occasionally these conditions could cause no symptoms in which case they are found accidentally when the patient is examined for other reasons or during autopsy. In this article we present the case of a 47-year-old male patient with triple congenital heart anomaly detected in two consecutive tests performed in pre-hospital medical care.

Overview of complications of acute and chronic myocardial infarctions: revisiting pathogenesis and cross-sectional imaging

Myocardial infarction (MI) remains one of the leading contributors to overall mortality and morbidity in the modern world, even with recent advances in medicine. Various complications can arise following an MI, particularly with delayed or inadequate treatment. Even though many of these complications are uncommon, they can have a significant impact on patient outcomes. Some of these complications can be diagnosed based on clinical, laboratory and echocardiographic evaluation. Other times, however, cardiac MR and multidetector CT are necessary in their diagnosis and proper evaluation. Accurate detection of these complications is an important aspect of optimising prompt and effective patient care, leading to better clinical outcomes. It is the goal of this article to review the role of cross-sectional imaging in patients with post-MI as well as the characteristic imaging findings and differential diagnosis of common and uncommon complications of MI.

Pentalogy of Cantrell

Pentalogy of Cantrell is a constellation of five congenital defects that pose a unique challenge for surgeons. Defects of the heart, pericardium, diaphragm, sternum, and anterior abdominal wall are pathognomonic. Although the incidence is low, it is critical to identify it in a timely fashion in order to adequately address all aspects. Early diagnosis, supportive care, and strategic surgical planning with a multidisciplinary team are all key components in managing patients with Pentalogy of Cantrell. In this text we sought to explore the evolution of both the understanding and treatment for this complex entity and provide current recommendations to today's pediatric caregivers.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know

Objective

Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT.

Conclusion

This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

Bleeding Meckel Diverticulum: A Retrospective Analysis of Computed Tomography Enterography Findings

OBJECTIVE

The aim of this study was to evaluate the computed tomography enterography (CTE) characteristics of bleeding Meckel diverticulum.

METHODS

The CTE images of 35 patients with Meckel diverticulum and gastrointestinal bleeding were retrospectively evaluated.

RESULTS

Meckel diverticulum was visualized in 33 of 35 patients and located in the right lower abdomen (20/33), midline lower abdomen (8/33), left lower abdomen (3/33), or paramedially near the umbilicus (2/33). The Meckel diverticulum was visualized on the antimesenteric side of the ileum in 16 patients (48.5%) and pointed toward the umbilicus in 10 (30.3%). The diverticulum appeared as a blind-ended tubular (22/33 [66.7%]) or saccular (11/33 [33.3%]) bowel segment. Separated supplying vessel was identified in 15 patients (45.5%) and associated with diverticulum (P = 0.037). The ectopic tissue was pathologically confirmed in 11 (33.3%) of 33 patients and was associated with diverticular nodules (P = 0.002).

CONCLUSIONS

Awareness of CTE features could aid in the preoperative assessment of bleeding Meckel diverticulum.

Catheter ablation of ventricular arrhythmia originating from isolated outflow tract diverticulum: Two case reports and literature review

RATIONALE

Congenital ventricular diverticulum is a rare cardiac malformation with a prevalence of about 0.26% in unselected adult patients during other diagnostic procedures. Ventricular arrhythmia originating from outflow tract diverticulum is even rarer and its etiology, epidemiology and proper treatment still remain controversial.

PATIENT CONCERNS

We present 2 cases of isolated outflow tract diverticulum incidentally revealed by cardiac angiography during catheter ablation for ventricular arrhythmia. The diverticulums in both cases were found to be the origins of the arrhythmia.

DIAGNOSES

The 2 patients were both diagnosed with ventricular arrhythmia originating from the outflow tract diverticulum.

INTERVENTIONS

Catheter ablation was successfully performed for case 1 while a conservative observation strategy was chosen for case 2.

OUTCOMES

Case 1 has been asymptomatic and free of premature ventricular contractions (PVCs) and both patients have no cardiac event during observational follow-up for 12 months.

LESSONS

For ventricular arrhythmia originating from outflow tract diverticulum, catheter ablation may be beneficial and choosing the mouth of the diverticulum or the outflow sites around as the ablation target may be reasonable. An observational follow-up strategy for the small and asymptomatic diverticulum may also be recommended.

Pentalogy of Cantrell: Is Echocardiography Sufficient in the Neonatal Period?

Pentalogy of Cantrell is a rare syndrome that is characterized by varying degrees of midline wall defects and congenital cardiac anomalies. A left ventricular diverticulum (LVD) is defined as partial ectopia cordis, can be part of the pentalogy of Cantrell, and can put the patient at risk of severe complications. Early diagnosis and ligation/resection of the LVD is important to prevent complications. We report on a case of pentalogy of Cantrell, in which a LVD was diagnosed only at 2 months of age despite preceding pre- and postnatal echocardiography. We conclude that in the suspicion of pentalogy of Cantrell, either complete or incomplete, cardiac magnetic resonance imaging should be performed, when possible, to avoid the potential complication of a herniating ventricular diverticulum.

Evolution of ventricular outpouching through the fetal and postnatal periods: Unabating dilemma of serial observation or surgical correction

Ventricular outpouching is a rare finding in prenatal sonography and the main differential diagnoses are diverticulum, aneurysm, and pseudoaneurysm in addition to congenital cysts and clefts. The various modes of fetal presentation of congenital ventricular outpouching include an abnormal four-chamber view on fetal two-dimensional echocardiogram, fetal arrhythmia, fetal hydrops, and pericardial effusion. Left ventricular aneurysm (LVA)/nonapical diverticula are usually isolated defects. Apical diverticula are always associated with midline thoracoabdominal defects (epigastric pulsating diverticulum or large omphalocele) and other structural malformations of the heart. Most patients with LVA/congenital ventricular diverticulum remain clinically asymptomatic but they can potentially give rise to complications such as ventricular tachyarrhythmias, systemic embolism, sudden death, spontaneous rupture, and severe valvular regurgitation. The treatment of asymptomatic LVA and isolated congenital ventricular diverticulum is still undefined. In this review, our aim is to outline a systematic approach to a fetus detected with ventricular outpouching. Starting with prevalence and its types, issues in fetal management, natural course and evolution postbirth, and finally the perpetual dilemma of serial observation or surgical correction is discussed.

Giant congenital left ventricular diverticulum associated with infective endocarditis: A diagnosis made by tissue Doppler echocardiography

Left ventricular (LV) diverticulum is a relatively rare condition, and it is important to differentiate it from pseudoaneurysm. The increasing use of noninvasive imaging modalities can help to demonstrate different types of ventricular outpouching structures. We report a case of congenital LV diverticulum that is much larger than the usual size and is diagnosed with tissue Doppler echocardiography and cardiac magnetic resonance imaging. Although a ventricular diverticulum is mostly asymptomatic, in the case of this particular patient, it has become complicated with infective endocarditis. <Learning objective: Congenital ventricular diverticulum is a rare finding and can be diagnosed with noninvasive imaging modalities such as tissue Doppler echocardiography and cardiac magnetic resonance imaging rather than surgery. Although congenital ventricular diverticulum is asymptomatic in most cases, infective endocarditis is a known complication.>.

Chest Pain With Apical Diverticulum in the Absence of Coronary Disease: Case Report and Review of the Literature

Aneurysmal dilatation of segment of the left ventricle in the absence of coronary disease has been reported and termed diverticulum, which appears to be a congenital anomaly. A 56-year-old white female was admitted to our hospital with chest pain that has been intermittent over the past 1 month. The pain was described as exertional, substernal and pressure-like in quality, radiating to left arm and jaw, and lasting approximately 30 minutes each episode; it was associated with shortness of breath. She has had approximately 10 such episodes in the past 1 month. The patient denied any dizziness, palpitations, syncope, orthopnea or paroxysmal nocturnal dyspnea (PND). She has had a history of hypertension for many years, however has not been compliant with her medications for the past 6 months. On admission, vital signs revealed blood pressure of 185/100 mm Hg, and regular heart rate of 94 beats per minute. Physical examination revealed a normal body habitus. Cardiac examination revealed no murmurs or extra cardiac sounds on auscultation. The pulmonary and abdomen examinations were unremarkable. The chest radiograph was normal. The electrocardiogram showed sinus rhythm, with borderline prolongation of the QT interval. The laboratory test results, including cardiac enzymes, were normal. Transthoracic echocardiography (TTE) revealed normal left ventricular systolic function, with localized dyskinesis of the apex. No significant valvular abnormalities were identified. Coronary angiography revealed angiographically normal coronary arteries; left ventriculography showed abnormal apical "filling defect" consistent with an aneurysm. A repeat echocardiogram using Definity contrast revealed left ventricular apical diverticulum with hypertrabeculation. The patient was placed on antihypertensive medications with resolution of her chest pain, and was able to ambulate comfortably. The patient was counseled thoroughly on the importance of compliance with her medications. This case describes an apical left ventricular diverticulum found incidentally and demonstrated on contrast echocardiography in a patient with chest pain.

Diverticulum, or not Diverticulum, That Is the Question! Discussing About a Case of Left Ventricular Outpouching Associated With Bicuspid Aortic Valve Assessed by Cardiac Magnetic Resonance

Congenital left ventricular outpouchings (LVOs) are infrequent myocardial malformations, comprising various overlapping abnormalities, whose characterization is often intricate in clinical practice using traditional non-invasive techniques. We describe a rare case of LVO associated with bicuspid aortic valve incidentally found in an asymptomatic adult patient. The LVO was located at basal level of the chamber, crescent-shaped with its largest diameter in short-axis view and presented a thin hypo-contractile wall without hyperintense areas on late gadolinium enhanced (LGE) images. This description corresponds to an overlap between usual definition of aneurism, fibrous and muscular diverticulum. The LVO was evaluated according with a classification recently proposed by Malakan Rad. In this case ventricular geometry was not respected, wall thickness was reduced and wall motion compromised therefore corresponding to a small IIc-type, which is considered having the poorest prognosis. Furthermore, the association with bicuspid aortic valve is very unusual. The patient refused surgery and preferred follow-up.