Surgical treatment of congenital left ventricular diverticulum

Abstract

Background: Congenital left ventricular diverticulum (LVD) is a rare cardiac malformation. Its prevalence rate is less than 0.1% of the congenital heart diseases requiring surgery. Some scholars suggest that all LVD should be actively removed to prevent possible risks, including diverticulum rupture, arterial embolism, and malignant arrhythmia. However, others believe that asymptomatic LVD can be followed up without immediate surgery. We reviewed and reported the diagnosis, clinical features, and surgical treatment of four cases of congenital LVD to provide clinical experience and a reference for the treatment of such patients.

Methods: Four patients (aged 3-32 years old) were diagnosed with congenital LVD and received surgical treatment at the Department of Cardiovascular Surgery of PLA General Hospital, Beijing, China from September 2009 to July 2019. All four patients had complete long-term postoperative follow-up data, including echocardiogram, enhanced cardiac computed tomography (CT), and electrocardiogram to monitor changes in left ventricular structure, heart function, and heart rhythm.

Results: In the first case, the fibrodiverticulum under the aortic valve squeezed the right ventricular outflow tract and the right main coronary artery; the morphology of the right ventricle and coronary artery returned to normal after surgery. The second patient was complicated with a huge lipoma in the apex of the left ventricle and underwent lipoma resection during LVD resection surgery. The third and fourth cases had muscular diverticula in the left ventricular apexes and received LVD removal surgery. All four patients recovered well after surgery and their left ventricular morphology and cardiac function were normal without adverse complications, such as atrial fibrillation, ventricular arrhythmia, and cerebrovascular accident.

Conclusions: Although the morphology and character of congenital LVD were different in each case, the use of effective diagnostic and follow-up tools, including echocardiogram, enhanced CT, and magnetic resonance imaging (MRI), allowed for successful surgical treatment of the left ventricular diverticula and symptoms or other malformations. We propose that congenital LVD should be actively treated with surgery, especially considering effectiveness and low risk associated with this therapeutic option.

Keywords: Left ventricular diverticulum (LVD); cardiac surgery; lipoma.

Figure 1

CT images of the LVD. (A) Coronal view; (B) sagittal view; (C) three-dimensional reconstruction showing that the LVD was under the aortic valve, adjacent to non-coronal cups. LA, left atrium; LV, left ventricle; RV, right ventricle; AO, ascending aorta; LVD, left ventricular diverticulum.

Figure 2

Surgical procedures of the LVD. (A) Exploration before cardiopulmonary bypass, [1] LVD, [2] right atrial appendage, [3] ascending aorta, [4] right coronary artery, [5] right ventricle; (B) incision and exposure of the diverticulum neck; (C) closure of the diverticulum neck with Decorn patch; (D) closure of the diverticulum cavity with two pieces of pericardium using the sandwich method. LVD, left ventricular diverticulum.

Figure 3

Postoperative view after resection and closure of the LVD. (A) Coronal view of enhanced cardiac CT showing that the morphology and structure of all cardiac chambers were normal; (B) sagittal view of enhanced cardiac CT showing that the LVD disappeared and the left ventricular morphology returned to normal. LVD, left ventricular diverticulum; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; AO, ascending aorta.

Figure 4

Images of the LVD with the left ventricular apical lipoma. (A) Coronal view of contrast-enhanced cardiac CT; (B) sagittal view of enhanced cardiac magnetic resonance; (C) coronal view of enhanced cardiac magnetic resonance. *, lipoma. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; AO, ascending aorta; LVD, left ventricular diverticulum.

Figure 5

Surgical procedures for the LVD combined with the giant lipoma in the left ventricular apex. (A) Exposure and exploration of the apical lipoma after cardiac arrest; (B) incision along the median of the lipoma and excision of the lipoma layer by layer; (C) exposing and cutting the base of the diverticulum apart to expose the neck of the diverticulum; (D) repairing and closing the neck of the diverticulum with Decorn patch; (E) closure of the diverticulum cavity with felt and Decorn patch using the sandwich method; (F) image after closing the left ventricle. *, the morphology returns to normal. LVD, left ventricular diverticulum.

Figure 6

Preoperative and postoperative echocardiography of the LVD combined with the giant lipoma in the left ventricular apex. (A) Preoperative echocardiography; (B) no diverticulum or lipoma were found in postoperative ultrasonography. *, lipoma. LV, left ventricle; LVD, left ventricular diverticulum.