Ann Thorac Surg 1997;64:1181-1182
© 1997 The Society of Thoracic Surgeons
Case Report
Ruptured Left Ventricular Diverticulum in Infancy
Stephen Westaby, FRCS,
Takahiro Katsumata, MD,
Martin Runciman, MRCP,
Michael Burch, MRCP
Oxford Heart Centre and Department of Paediatric Cardiology, John Radcliffe Hospital, Oxford, United Kingdom
Accepted for publication April 29, 1997.
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Abstract
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Congenital diverticulum of the left ventricle is rare, and rupture of such a diverticulum is even more rare. We describe successful surgical repair of a ruptured left ventricular diverticulum in an 11-month-old infant.
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Introduction
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Aneurysms of the left ventricle are rare in the pediatric age group. Developmental diverticuli and traumatic left ventricular aneurysms have been described previously [1, 2]. Coronary artery anomalies may cause acute myocardial infarction followed by aneurysm formation, but rupture and pericardial tamponade are distinctly unusual.
A previously healthy 11-month-old female infant presented with an episode of syncope. On admission to hospital she was clinically shocked with a hemoglobin level of 9.0 g/dL. When a plain chest roentgenogram showed cardiomegaly, an echocardiogram was arranged. This showed distention of the pericardium by blood but a vigorous left ventricle and an enormous apical left ventricular diverticulum (Fig 1
). The diverticulum was thin-walled and had a pedicle of external thrombus occluding the site of rupture. Detailed inspection failed to suggest a coronary artery anomaly, and there was no history of trauma. Although the diverticulum was situated within the pericardial sac, this bulged into the left chest, causing hypoplasia of the left lower lobe.
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Fig 1. . Preoperative echocardiogram showing a large, noncontractile apical diverticulum surrounded by a pericardial collection. (An = aneurysm; Ao = aorta; LV = left ventricle; PE = pericardial effusion.)
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At operation through a median sternotomy, the pericardium was found to be tense with blood. Relief of tamponade increased the systolic pressure from 55 mm Hg to 90 mm Hg. The aorta and right atrium were cannulated quickly for cardiopulmonary bypass before thrombus was disturbed around the apical aneurysm. An aortic cross-clamp was then applied and the heart arrested with 150 mL of St. Thomas' cardioplegia delivered directly into the aortic root. Blood and thrombus were evacuated from the pericardium, and the site of rupture was identified (Fig 2). The diverticulum was opened and had a 6-mm ostium into the left ventricle. The left ventricle itself was of normal size and the coronary arteries were normal. The diverticulum was amputated from the apex of the left ventricle, and the entry site was oversewn. The operation was completed uneventfully and the infant made a rapid and uncomplicated recovery. Histologic examination of the excised specimen showed an endothelialized wall 3 mm in thickness containing residual muscle fibers and generalized interstitial edema.
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Comment
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Although they are exceptionally rare, there are numerous previous reports of left ventricular aneurysms in infancy [3–5]. These are broadly classified into developmental diverticuli, aneurysms in association with coronary anomalies, or posttraumatic aneurysms. Operative treatment of ventricular diverticulum has been recommended because of the possibility of rupture, systemic thromboembolism, or impaired ventricular function. The narrow-necked muscular diverticulum is frequently associated with a midline defect in the chest or abdominal wall [6]. Associated intracardiac anomalies are common [7]. Our patient was developmentally normal and symptom free before the syncopal event.
In this case the thin-walled left ventricular diverticulum was exceptionally large in relation to the native left ventricle with a neck two-thirds the diameter of the aortic annulus. The infant probably survived free rupture of the diverticulum when an acute rise in intrapericardial pressure collapsed the thin-walled structure, allowing blood clot to occlude the tear. The surgical strategy was to sedate and ß-block the child and establish cardiopulmonary bypass quickly. Relief of tamponade elevated the systemic pressure with the risk of secondary hemorrhage. Once we avoided this, aneurysm excision and repair of the apex were uncomplicated. Our experience suggests that identification of a left ventricular diverticulum should be followed by an operation. Currently there is insufficient evidence to debate the relationship between aneurysm size and risk of rupture.
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Footnotes
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Address reprint requests to Mr Westaby, Oxford Heart Centre, Headington, Oxford, OX3 9DU, United Kingdom.
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References
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- Rheuban KS, Tompkins DG, Nolan SP, Berger B, Martin R, Schneider A. Myocardial necrosis and ventricular aneurysm following closed chest injury in a child. J Trauma 1981;21:170–3.[Medline]
- Grossi EA, Colvin SB, Galloway AC, et al. Repair of posterior left ventricular aneurysm in a six-year-old boy. Ann Thorac Surg 1991;51:484–7.[Abstract]
- Mandy C. Left ventricular diverticulum: an analysis of two operated cases and review of the literature. Angiology 1982;33:280–6.[Free Full Text]
- Walton-Shirley M, Smith SM, Talley JD. Left ventricular diverticulum: case report and review of the literature. Cathet Cardiovasc Diagn 1992;26:31–3.[Medline]
- Hamaoka K, Onaka M, Tanaka T, Onouchi Z. Congenital ventricular aneurysm and diverticulum in children. Pediatr Cardiol 1987;8:169–75.[Medline]
- Cantrell JR, Haller A, Ravitch M. A syndrome of congenital defects involving the abdominal wall, sternum, diaphragm, pericardium and heart. Surg Gynecol Obstet 1958;107:602–14.[Medline]
- Murphy DA, Aberdeen E, Dobbs RH, Waterston DJ. The surgical treatment of a syndrome consisting of thoracoabdominal wall; diaphragmatic, pericardial and ventricular septal defects; and a left ventricular diverticulum. Ann Thorac Surg 1968;6:528–34.[Medline]
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Abstract
Introduction
