Diverticular and aneurysmal structures of the left ventricle in adults: report of a case within the context of a literature review

Abstract

Left ventricular outpouchings are increasingly detected on cardiovascular imaging. Herein, we describe the case of a 45-year-old man who underwent noncardiac preoperative imaging and was found to have an asymptomatic left ventricular outpouching. The patient underwent successful surgical repair of the structure. When left ventricular outpouchings are detected, the main differential diagnoses are pseudoaneurysm, aneurysm, and diverticulum. The outcomes for these conditions differ substantially, and accurate diagnosis can be crucial in making clinical decisions. We review the relevant medical literature, outline the natural history of these left ventricular abnormalities, and discuss options in regard to their management.

Keywords: Aneurysm, false/diagnosis/mortality/surgery; cardiomyopathies/diagnosis/epidemiology/therapy; diagnosis, differential; diverticulum/congenital/diagnosis/surgery; heart aneurysm/diagnosis/etiology/mortality/physiopathology/radiography/surgery; heart defects, congenital/complications/diagnosis/surgery; heart rupture, post-infarction/etiology/therapy; heart ventricles/abnormalities/pathology/surgery; myocardial infarction/complications; treatment outcome; ventricular septal rupture/etiology.

Fig. 4 Cardiac computed tomographic angiography shows a 4.1 × 3.1 × 4.3-cm chamber-like structure arising from the left ventricle in the A) apical–lateral and B) inferoapical region. The wall of the chamber appears to have myocardium of variable thickness, with substantial thinning at the upper lateral aspect.

Fig. 3 Left ventriculography shows A) the filling of the apical aneurysm-like structure in diastole, B) the persistence of contrast medium in systole, and C) lingering contrast medium several beats after its clearance from the left ventricle. D) Coronary angiography shows lesions in the proximal and distal left anterior descending coronary artery.

Fig. 2 Echocardiographic A) 4-chamber and B) 2-chamber apical views show the apical–lateral aneurysm-like abnormality. Off-axis images of the outpouching, with the use of color-flow Doppler echocardiography, show C) systolic inflow and D) diastolic outflow.

Fig. 1 Myocardial single-photon-emission computed tomographic (SPECT) perfusion was performed with use of a dipyridamole thallium-sestamibi dual-isotope protocol. The left ventricle was dilated and hypertrophied with thinning and bulging in the region of the apical–lateral wall, suggesting aneurysm (arrows). There was homogenous uptake of thallium and sestamibi in the remainder of the myocardium, with no evidence of ischemia.

Fig. 5 Intraoperative photographs show A) a left ventricular outpouching (arrow), and B) a septum, with a small hole, that separates the accessory chamber from the main ventricular cavity.

Fig. 6 Photomicrographs of the congenital fenestrated septum show dense fibrous tissue. A) No myocardial elements are seen in this section (H & E, orig. ×2). B) The lateral wall of the outpouching shows myocardial tissue with an area of fibrous scarring that indicates a healed myocardial infarction (H & E, orig. ×4).