Congenital left ventricular outpouchings: a systematic review of 839 cases and introduction of a novel classification after two centuries

Left ventricular inferior wall congenital diverticula in athletes: a case series and review of the literature

Background

Congenital left ventricular diverticula (LVDs) and aneurysms (LVAs) are rare, developmental, cardiac anomalies, which are often asymptomatic. Sometimes they can cause life-threatening complications like arrhythmias, syncope, embolic events, ventricular wall rupture, valvular regurgitation, congestive heart failure, and various symptoms. Diagnosis is usually made after exclusion of acquired causes, from cardiac or non-cardiac disorders. Specific guidelines for LVD/LVA management are not available and treatment options are guided by different case-by-case clinical presentation and possible complications.

Case summary

We present a series of two patients with occasional diagnosis of diverticula of the inferior basal left ventricular wall in the context of cardiological evaluations for competitive sport certificate. Symptoms were present at clinical evaluation only in Patient 1, together with electrocardiogram (ECG) abnormality. We performed transthoracic echocardiography as a first-line examination and secondly, we confirmed the diverticula by cardiac magnetic resonance. A maximal stress test and 24 h ECG Holter were also performed.In our case, in light of the clinical-instrumental findings, periodic medical and echocardiographic follow-up without therapy was established, together with the resumption of sports activities.

Discussion

Nowadays, no specific recommendations exist in athletes and no studies are available on how regular sport practice can influence natural history of LVD/LVA. The current case series highlights the importance of risk stratification for cardiac events, of a multimodal imaging approach in diagnostic procedure and of a tailored treatment strategy.

Prenatal features and postnatal follow-up of congenital ventricular outpouching: A retrospective study of two centers in China

OBJECTIVES

Congenital ventricular outpouching (CVO) is a rare cardiac malformation that can manifest as congenital ventricular aneurysm (CVA) and/or congenital ventricular diverticula (CVD). In this study, we describe the prenatal features and postnatal follow-up of 27 cases of CVO.

METHODS

The clinical data of 27 patients with CVO who attended Sir Run Run Shaw Hospital Affiliated to the Medical College of Zhejiang University (Zhejiang Province, China) and Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University (Zhejiang Province, China) from April 2013 to October 2022 were retrospectively analyzed. The patients were also followed up by telephone. The prenatal characteristics and postnatal outcomes of the patients with CVO were evaluated.

RESULTS

CVO was detected in 26 cases prenatally, 14 (51.85%) were diagnosed with CVA, nine (33.33%) were diagnosed with CVD, three (11.11%) were equivocal for CVA/CVD, and one (3.70%) was detected with CVA postnatally. Six patients underwent follow-up fetal echocardiography approximately 4 weeks after the initial echocardiography examination, and a significant difference in CVO size was observed between the two examinations (P = .02). Eight patients (29.63%) demonstrated cardiovascular dysfunction, and the median CVO size in fetuses with and without cardiovascular dysfunction was 205 (range: 169-396) mm2 and 124 (range: 92-154.5) mm2 , respectively (P = .01). Correlation was found between CVO size and fetal cardiac dysfunction (p = .000, r = .778). Eight patients (29.63%) had cardiac/extracardiac defects. Thirteen patients were live born, 12 were terminated pregnancies, and two were lost to follow-up. The postpartum size of the CVOs remained stable in six patients, decreased in two patients, dissolved in three patients, and were surgically removed in two patients. With the exception of one patient with CVA complicated with complex congenital cardiac malformation who underwent surgical treatment after birth and who had postoperative left ventricular dysfunction (Case 1), the prognosis of all of the patients was good.

CONCLUSION

CVO is often associated with cardiac malformations. The size of prenatal CVOs can increase with gestational development, and cardiovascular dysfunction is significantly related to CVO size. The postpartum prognosis of patients with CVO is good. Echocardiography plays a key role in the diagnosis of congenital ventricular outpouching. Prenatal counseling should be cautious regarding the diagnosis and the prognosis although our cases had a favorable prognosis.

Congenital giant left ventricular aneurysm

We report a case of congenital giant left ventricular aneurysm with severely depressed systolic cardiac function who underwent early surgical resection with subsequent recovery of left ventricular systolic function.

Double chambered left ventricle-institutional experience of two cases

BACKGROUND

Double Chambered Left Ventricle is a very rare congenital cardiac condition with limited cases reported in literature, etiology of which is obscure and presentation can be varied.

AIM OF THE STUDY

To share our experience of two diverse cases of Double Chambered Left Ventricle at our institute.

RESULTS

Two diverse cases of Double Chambered Left Ventricle were appropriately diagnosed and successfully managed. One of which one was congenital and the other was acquired METHODS: Both the patients had an uneventful peri-operative period.

CONCLUSIONS

Double Chambered Left Ventricle is a condition which remains an enigma. Diagnosis requires a high degree of radiological suspicion for prompt diagnosis and good surgical outcomes.

Submitral aneurysm communicating with coronary sinus in a child

A newborn girl was referred for a suspected abnormal pulmonary venous return in coronary sinus. Echocardiogram revealed a large outpouching of the left ventricle creating an accessory cardiac chamber that was connected to the left ventricle behind the mural leaflet of the mitral valve, and with the right atrium via the coronary sinus. Ten years later, the orifice between the submitral aneurysm and the left ventricle was closed percutaneously.

Left ventricular diverticulum: A case report and review of the literature

Left ventricular diverticulum is a rare congenital left ventricular outpouchings. The disease is often diagnosed during childhood because it is frequently associated with midline thoracoabdominal defects and other congenital cardiac anomalies. Most cases are asymptomatic, often discovered incidentally. Some complications have been reported including infarction, arrhythmia, heart failure. The most severe complication is rupture of the diverticulum, which can cause a patient's death. Therefore, this congenital defect should be detected early to assess potential risks for appropriate treatment. In this article, we report a case of a 3-month-old boy with left ventricular diverticulum diagnosed with Doppler ultrasound and cardiac MSCT. Complete resection was undertaken. The patient remained asymptomatic with good heart function 2 months after surgery.

Treatment decision in a 4-year-old-boy with left ventricular outpouching after advanced hemodynamical flow evaluation with 4Dflow CMR: A case report

BACKGROUND

The present study presents a diagnostic course for the characterization of a congenital left ventricular outpouching (LVO) in a 4-year-old boy with severe neonatal heart failure, evaluating the added value of cardiac magnetic resonance (CMR) 4Dflow.

CASE PRESENTATION

A boy, born at full term, presented with heart failure immediately after birth. Echocardiography showed dilated left ventricle with poor function and LVO was initially interpreted as an aneurysm. No infection, inflammation, or other cause for heart failure was found. With intensive medical treatment, the heart function returned to normal, and eventually, all medication was terminated. At follow-up, surgical treatment of the LVO was discussed but after CMR 4Dflow, a thorough evaluation of the function of the left ventricle as well as the LVO was possible and the LVO was determined a double-chambered left ventricle with a good prognosis.

CONCLUSIONS

The present case demonstrates the clinical usability of CMR 4Dflow for improved decision-making and risk assessment, revealing advanced hemodynamic flow patterns with no need for operation.

[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.

Diagnosis of Double-chambered Left Ventricle of Superior-inferior Type by Echocardiography: A Retrospective Study of 9 Subjects across Two Heart Centers

BACKGROUND

Double-chambered left ventricle (DCLV) is extremely rare. Challenges remain in accurate diagnosis of DCLV by echocardiography, because it is easily confused with left ventricular diverticulum, left ventricular aneurysm, ventricular septal defect, etc. Herein, we reviewed echocardiographic characteristics of DCLV and evaluated the accuracy of echocardiographic diagnosis.

METHODS

Clinical and echocardiographical databases of two heart centers were reviewed. Nine children with DCLV of superior-inferior arrangement were studied retrospectively.

RESULTS

Normal elliptical geometry of LV cavity is preserved in DCLV. Fibromuscluar bundles separate LV into the main chamber and the accessory chamber. The associated malformations included ventricular septal defects, mitral regurgitation, mitral valve stenosis, pulmonary stenosis, and left ventricular noncompaction in our study. Eight of nine subjects with DCLV of superior-inferior arrangement were diagnosed correctly by initial echocardiographic examination, and one case was mistaken as left ventricular diverticulum.

CONCLUSIONS

Double-chambered left ventricle could be diagnosed and followed up by echocardiography. The morphological classification is a simplified way to improve diagnostic accuracy.

Congenital Aneurysm/Diverticulum of the Left Ventricle in the Newborn

Left ventricular aneurysms and diverticula are severe congenital heart defects. The low prevalence and mostly asymptomatic course of these anomalies do not always allow us to suspect these defects in time and to differentiate them among themselves. That is why early detection of pathology with the help of fetal echocardiography is a key factor in determination of the tactics of patients’ management. The paper reviews the literature and describes a complex case of prenatally diagnosed left ventricular aneurysm.

Two in One: Echocardiographic Features of Right-Ventricular Diverticulum and Left-Ventricular Aneurysm in the Same Patient

Ventricular diverticulum is a rare congenital heart defect that is usually found incidentally upon imaging, such as 2-dimensional transthoracic echocardiogram. We report a case in which an isolated right-ventricular diverticulum and a left-ventricular aneurysm were both found on transthoracic echocardiogram in the setting of a pulmonary embolism. This case highlights how to distinguish between an aneurysm and a diverticulum based on wall motion on echocardiogram, as well as potential complications that may arise from either anomaly.

A Japanese Patient with Genitopatellar Syndrome Transiently Presenting with Cardiac Intramural Cavity during the Neonatal Period

Genitopatellar syndrome (GPS) is a rare autosomal dominant disorder caused by de novo pathogenic variants in the KAT6B gene. It is characterized by genital abnormalities, patellar hypoplasia/agenesis, flexion contractures of the hips and knees, corpus callosum agenesis with microcephaly, and hydronephrosis and/or multiple renal cysts. More than half of patients with GPS have congenital heart defects, mostly atrial and/or ventricular septal defects, patent foramen ovale, and patent ductus arteriosus. We report a case of a Japanese neonate with a de novo heterozygous c.3769_3772delTCTA pathogenic variant in the KAT6B gene who presented with a cardiac intramural cavity of the ventricular septum at birth. The cavity unexpectedly disappeared at 1 month of age, but trabecular septal thinning and flash remained. The features of the cavity were not consistent with those of congenital ventricular diverticulum or aneurysm, and its identity and prognosis are still unclear. Because patients with GPS may exhibit various forms of cardiac malformation, careful cardiac examination and follow-up are required from birth in cases of suspected GPS.

Partial resection of large congenital left ventricular diverticulum in an infant: a case report

BACKGROUND

Congenital left ventricular diverticulum is a rare cardiac malformation usually requiring total resection.

CASE PRESENTATION

This report describes an infant presenting with a large apical diverticulum with a wide ventricle connection. Given the vicinity of the left anterior descending coronary artery to the diverticulum and its wide ventricular connection, partial resection was undertaken. The patient remained asymptomatic with good heart function 8 months after surgery. The last follow-up echocardiography did not demonstrate any significant left ventricular outpouching.

CONCLUSIONS

We advocate early treatment of left ventricular diverticulum in children given the risk of spontaneous rupture of diverticulum, sudden death, and other serious complications if left untreated. For small patients with a wide connection of diverticulum to ventricle, partial resection is a safe option with favorable short-term outcomes.

Accessory left ventricular chamber in a cat: multimodality imaging description by cardiac magnetic resonance imaging and echocardiography

A left ventricular accessory chamber is a complex and uncommon phenotype consisting in a subdivision of the left ventricle by a thick-walled muscle bundle or septum into two cavities. Multiple aetiologies such as congenital double-chambered left ventricle and acquired endomyocardial form of restrictive cardiomyopathy have been reported. The endomyocardial form of restrictive cardiomyopathy, owing to its structural heterogeneity, can present a similar phenotype to the congenital abnormality with intraventricular lesions bridging the ventricular septum and left ventricular free wall. Conventional echocardiography is the first-line, accepted, non-invasive imaging modality to investigate underlying cardiac disease but presents limitations for the overall assessment of myocardial tissue. This report describes the use of cardiac magnetic resonance imaging as an additional imaging modality to provide multiplanar morphological, structural, and functional information of the myocardium. In the presented images, hyperintensities on cardiac magnetic resonance imaging within the myocardium along with hyperechoic and heterogeneous myocardial tissue on echocardiography and elevated troponin I were suggestive of a presumptive acquired pathological process such as feline endomyocarditis-left ventricular endomyocardial fibrosis complex, rather than a sole congenital anomaly. Although the diagnosis was not confirmed, this case exemplifies the advantages of using complementary multimodality imaging in a cat presented with a left ventricular accessory chamber.

Autopsy and postnatal follow-up of prenatally diagnosed ventricular outpouchings

OBJECTIVES

Prenatal ventricular outpouchings (VOs), which include congenital ventricular aneurysms (CAs) and congenital ventricular diverticula (CD), are very rare. We describe the features and outcomes of prenatal VOs diagnosed over a 4-year period.

METHODS

Retrospective cohort study of cases of prenatal diagnoses of CAs and CD at our center between June 2014 and January 2018. The prenatal and postnatal echocardiogram data were reviewed, and telephone follow-up was conducted of liveborn cases.

RESULTS

A total of 25 VOs were identified. Two were lost to follow-up, 15 chose termination of pregnancy, and eight resulted in livebirths. Only two cases underwent autopsy: Histopathology showed that the CA wall was substituted by collagen fibers. At follow-up, none of the eight liveborn babies experienced adverse events, and three VOs near the tricuspid annulus almost disappeared, though one was extremely large.

CONCLUSIONS

In our center, all liveborn babies with VO had good prognoses. We hypothesize that VOs located near the right ventricular annulus may be caused by prenatally unbalanced pressure, given their decrease in size after birth when the right heart pressure declines.

Prenatally Diagnosed Congenital Ventricular Outpouchings: An Institutional Experience and Review of the Literature

Congenital ventricular outpouchings (CVOs) are rare congenital heart defects with limited data regarding prognosis and outcomes. We aimed to describe the characteristics, outcomes and factors associated with morbidity and mortality of prenatally diagnosed CVOs using our institutional experience and a review of published cases. A total of 86 cases of prenatally diagnosed CVOs were identified, including 3 from our institution and 83 cases identified from a review of the literature. Fetal and postnatal outcomes were analyzed for each case. Pericardial effusions (44%) and ventricular dysfunction (17%) were the most common associated findings. Excluding cases that resulted in pregnancy termination, mortality was 17%, with the majority (11/13) occurring in the prenatal period. Factors associated with mortality included an outpouching located on the left ventricle, a diagnosis of hydrops fetalis, the presence of a pericardial effusion, and an earlier gestational age at diagnosis. Of those that survived to delivery, 57% remained asymptomatic without the need for intervention, and the outpouching regressed or resolved in an additional 15%. Prenatally diagnosed congenital ventricular outpouchings are a dynamic form of congenital heart disease with a high fetal mortality rate. The outcomes associated with the outpouchings appear to be the most variable in the prenatal period and the first year after birth. Serial prenatal and postnatal evaluations should be performed to evaluate for a change in the characteristics of the outpouching.

Multiple congenital ventricular diverticula causing heart failure

This paper reports a case of multiple congenital ventricular diverticula, a rare anomaly that is associated with heart failure.

Multimodality Imaging and Clinical Significance of Congenital Ventricular Outpouchings: Recesses, Diverticula, Aneurysms, Clefts, and Crypts

The high spatial resolution of cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) permit the diagnosis of congenital ventricular outpouchings (CVOs), including congenital ventricular diverticula (CVD), congenital ventricular aneurysms (CVA), clefts, and crypts. A unique classification has not been established, and these terms are used interchangeably with confounding terminology. Moreover, their significance is not univocal. A research was performed using PubMed on six subjects: (1) congenital left ventricular outpouchings; (2) congenital ventricular diverticulum; (3) congenital ventricular aneurysm; (4) ventricular clefts; (5) ventricular crypts; and (6) ventricular crevices. Usually, CVOs are small with a preserved contraction and in asymptomatic patients, the clinical relevance may be minimal, although electrocardiographic anomalies are often present. CVA and diverticula may carry an embolic risk and cases of arrhythmia and rupture are described. In the presence of clefts, or crypts a cardiomyopathy should be excluded. A simple classification can be proposed: CVD extend beyond the myocardial wall and fibrous type may be termed CVA, acquired forms should be kept distinct. Clefts, or crypts, are small recesses extending for more than 50% of the ventricular wall but not beyond its margin. The presence of fibrosis may be evaluated by CMR. A multicenter prospective registry would be helpful to investigate potential clinical implications and to exclude dubious forms of hypertrophic cardiomyopathy or ventricular noncompaction. In conclusion, CVOs have been described with different terminologies and classifications. Their significance needs to be interpreted in the clinical setting and with the help of a multimodality imaging, particularly of CMR.

An abnormal structure of the left ventricle

CLINICAL INTRODUCTION: A 36-year-old man was referred for evaluation of an abnormal left ventricular (LV) structure found incidentally on transthoracic echocardiography (TTE) (figure 1). He had no symptoms except for mild palpitations. There was no significant medical history. Physical examination was unremarkable. ECG showed regular sinus rhythm with ST changes in lead II, III, avF and V6 (see online supplementary file 1). Cardiac magnetic resonance (CMR) (figure 1C) was performed. Treadmill exercise test did not demonstrate any electrocardiographic ischaemic changes. No arrhythmias were noted on Holter monitor. Which of the following is most likely the diagnosis?DC1SP110.1136/heartjnl-2017-312068.supp1Supplementary file 1 heartjnl;104/2/182/F1F1F1Figure 1Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). (A) Parasternal left ventricular longitudinal axis view of TTE; (B) colour Doppler of parasternal left ventricular longitudinal axis view of TTE; (C) left ventricular longitudinal axis view of CMR.

QUESTIONS

A: Lateral and inferolateral myocardial infarctionB: Congenital absence of pericardiumC: PseudoaneurysmD: Congenital left ventricular outpouching.

Left Ventricular Aneurysm: Sudden Unexpected Deaths in a 29-Year-Old Man

Left ventricular aneurysm (LVA) is an abnormal dilated heart structure, either congenital or acquired. LVA is a rare cardiac condition with no symptoms in most cases, thus occasionally diagnosed during investigations of other diseases. Its association with certain cardiac complications and sudden cardiac deaths has been reported. However, its role as a cause of sudden unexpected death is rare. The author reported a sudden cardiac death in a 29-year-old man with LVA. Without a significant coronary artery disease and known etiologies of LVA, such an abnormal heart structure in the present case was considered congenital LVA. As no other possible mechanisms of death could be identified other than LVA with its associated pathologic lesions, mural thrombi, and dilated cardiomegaly, his death was attributable to fatal cardiac arrhythmia (most commonly ventricular tachycardia) secondary to LVA.

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.

Emergency Cesarean Section in Case of Aneurysm of the Muscular Intraventricular Septum with Neonatal Follow-up - A Case Report and Review of the Literature

We present the case of aneurysm of the muscular intraventricular septum with accompanying cardiomegaly and abnormal venous flow patterns requiring emergency cesarean section and specialized neonatal treatment. At the age of 8 months our patient has no clinical symptoms with a 6 mm scar in intraventricular muscular septum..

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.