Vascular Disease

Left Ventricular Diverticula

Alexander J. Sweidan, MD
Sarah J. Strube, DO
Serap Erdogdu-Sobnosky, MD
University of California, Los Angeles- St. Mary’s Medical Center, Department of Internal Medicine, Long Beach, CA

 

A 42-year-old female with a past medical history significant for systemic lupus erythematous presented with dyspnea and an abnormal electrocardiogram (ECG). The ECG showed a right bundle branch block and bilateral atrial enlargement. Echocardiogram showed an ejection fraction of 78%, severe right atrial enlargement, moderate left atrial enlargement, and severe right ventricle enlargement. There was minimal mitral regurgitation, tricuspid insufficiency, and aortic insufficiency. The findings were concerning for pulmonary hypertension from lupus vs coronary artery disease. A coronary angiogram found no significant stenosis in the patient’s coronary arteries, but the left ventriculogram showed multiple diverticula (Video). The right heart catheterization was consistent with pulmonary hypertension. Though left ventricular diverticula (LVD) in this case are an incidental finding, their existence does carry risk. Understanding LVD epidemiology, pathophysiology, and their associated risk are in order.

Cardiac diverticula are rare and typically arise from the left ventricle. Cardiac diverticula are outpouching structures that contain endocardium, myocardium, and pericardium and display normal contraction.1 Earlier reports have identified a prevalence of 0.4%, or 3 in 750 cases, of cardiac necropsy cases.2 Extracardiac anomalies are associated with 32.7% of LVD cases.3 Diverticula are usually localized near the apex and most often involve the inferior or anterior parietal walls of the left ventricle.1 It is important to separate a congenital diverticulum from acquired aneurysm, given that the former carries a benign course and the latter is associated with ominous causes, such as myocardial infarction, myocarditis, or post-operative cardiothoracic complications.4 Rupture is the leading cause of cardiac death in left ventricle diverticula.3

Example of left ventricular diverticulum:

References:

  1. Skapinker S. Diverticulum of the left ventricle of the heart: review of the literature and report of a successful removal of the diverticulum. AMA Arch Surg. 1951;63(5):629–634. doi:10.1001/archsurg.1951.01250040643009.
  2. Pressoir R, Downing JW. Congenital diverticula of the right ventricle of the heart: a case report. J Natl Med Assoc. 1980;72(3):262–264. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552564/pdf/jnma00035-0096.pdf.
  3. Ohlow M-A, von Korn H, Lauer B. Characteristics and outcome of congenital left ventricular aneurysm and diverticulum: analysis of 809 cases published since 1816. Int J Cardiol. 2015;185:34-45. doi:10.1016/j.ijcard.2015.03.050.
  4. Kosar F, Sahin I, Gullu H. Isolated large true contractile left ventricular diverticulum mimicking ischemia in an adult patient: a case report. Heart Vessels. 2005;20(2):85-87. doi:10.1007/s00380-004-0775-7.