Left ventricular diverticulum vs. ventricular septal defect vs. ventricular aneurysm
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Left ventricular diverticulum vs. ventricular septal defect vs. ventricular aneurysm Aleksandra Milovančev1,2 · Mila Kovačević1,2 · Aleksandar Lazarević2 · Aleksandra Ilić1,2 · Stefanović Maja1,2 · Anastazija Stojšić‑Milosavljević1,2 Received: 5 September 2020 / Accepted: 9 September 2020 © Springer Nature B.V. 2020
The distinction between various left ventricular outpouchings in adulthood is challenging particularly in the setting of various clinical presentations. Left ventricular (LV) outpouchings are characterized as localized protrusions of the ventricular wall and can be differentiated into diverticula and aneurysms [1]. While LV diverticula (LVD) contain all three layers of the ventricular wall and contract synchronously with the rest of the myocardium, LV aneurysms are akinetic or dyskinetic, usually with a wider neck. We herein describe accidentally diagnosed LVD in three different clinical presentations. A 37-year-old man complained of palpitation. Ambulatory 24-h electrocardiogram (ECG) revealed repetitive ventricular premature beats and stress ECG nonsustained ventricular tachycardia. Computed tomography (CT) coronary angiography showed normal coronary arteries but revealed left ventricular diverticulum (LVD) in the mid/basal inferoseptum (Panel A, B). Cardiac magnetic resonance (CMR) was indicative of LVD as well (Panel C). The patient was referred to an electrophysiologist for further diagnostic and treatment. A 59-year-old man with a past medical history of coronary artery disease was admitted due to chest pain and slight elevation of hsTroponin I. Coronary angiography (CA) revealed chronic total occlusion of the medial segment of the right coronary artery with good collateral circulation. Echocardiography showed a hypokinetic basal segment of the left ventricular (LV) inferior wall and small outpouching
in the inferior/inferoseptal segment raising suspicion for postinfarction ventricular septal defect (VSD)(Panel D, Video 1). Left-sided contrast echocardiography depicted LVD in mid-inferoseptum (Panel E), which was confirmed by CT (Panel F). The third patient, a 53-year-old woman was referred to our hospital due to suspicion of ST-segment elevated myocardial infarction. Urgent CA didn’t show culprit lesion. Left ventriculography showed apical ballooning suggestive to Takotsubo syndrome and outpouching of the inferobasal wall (Panel G, Video 2). Echocardiography beside wall motion abnormalities demonstrated LVD in the basal/mid inferoseptum (Panel H). After 6 weeks CMR showed normal LV function and confirmed LVD (31 × 20 × 8 mm) with preserved contractility in inferoseptum and another smaller (6 × 6 mm) muscular type diverticulum was detected in the apical region as well (Panel I). In the last two cases, optimal medical therapy was proposed. The specificity of these case reports is the accidental finding of LVD which in the first case is associated with rhythm disorders, in the second case raised suspicion of postinfarction VSD and in the third case of LV aneurysm. Howeve
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