Ann Thorac Surg 1998;66:1421-1423
© 1998 The Society of Thoracic Surgeons
Case Reports
Repair of left ventricular diverticulum with ventricular bigeminy in an infant
Hiroaki Kawata, MDa,
Hidefumi Kishimoto, MDa,
Takayoshi Ueno, MDa,
Futoshi Kayatani, MDb,
Tohru Mori, MDa
a Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
b Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
Accepted for publication April 28, 1998.
Address reprint requests to Dr Kawata, Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi City, Osaka 594-1101, Japan
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Abstract
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Surgical repair of left ventricular diverticulum usually is not required in infancy even though it combines with other anomalies. In addition to prevention of rupture of the diverticulum and thrombus formation, treatment of combined ventricular tachycardia is thought to be an indication for resection of the diverticulum. We describe a successful repair performed by excising the isolated left ventricular diverticulum under cardiopulmonary bypass in a 9-day-old infant. The combined ventricular bigeminy has disappeared 9 months after the operation.
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Introduction
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Isolated left ventricular diverticulum is a rare and usually asymptomatic cardiac malformation. Surgical treatment of this anomaly usually is not required during infancy even though the diverticulum is associated with other congenital anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Under cardiopulmonary bypass, we resected the left ventricular diverticulum of a 9-day-old boy who had suffered from ventricular bigeminy.
A 2,882-g male infant was born with a diagnosis of fetal arrhythmia and left ventricular diverticulum, which had been detected at 36 weeks’ gestation by prenatal ultrasound scanning. Congestive heart failure with symptoms such as vomiting, oligonuria, cardiomegaly, and systemic edema were controlled with conservative therapies such as diuretics. However, ventricular bigeminy with monofocal premature ventricular contractions (PVCs), which had begun on his second day of life, increased its frequency. The bigeminy recovered to sinus rhythm spontaneously in a few minutes, but occurred several times an hour even during a rest period such as sleeping. No cardiac murmur was heard. The liver was palpable 1 cm at his subcostal space. There were no other associated malformations such as midline thoracic, diaphragmatic, or abdominal wall defects.
Ultrasonic echocardiography suggested a left ventricular diverticulum at the apex with a diameter of 20 mm. The posterior wall looked thin and fibrous. There was no thrombus detected in the diverticulum. Mitral valve regurgitation was not detected. No other intracardiac abnormalities were shown except a patent foramen ovale. A left ventricular cineangiogram also showed a large diverticulum at the apex with a narrow connection to the left ventricular cavity. The end-diastolic volume index of the left ventricle including and excluding the diverticulum were estimated as 73.5 mL/m2 (145% of normal left ventricle) and 40 mL/m2 (79%), respectively (Fig 1). The ejection fraction of the whole left ventricle and the true left ventricle excluding the diverticulum were 0.37 and 0.51, respectively. The diverticulum contracted synchronously with the true left ventricle but hypokinetically at the thin-walled posterior wall. There were no anomalies of coronary arteries. The electrocardiogram showed bigeminy with monofocal PVCs, which were thought to originate from the posteroinferior wall of the ventricle (Fig 2).
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Fig 1. Frontal view of left ventriculogram at end-diastolic (A) and end-systolic phase (B). End-diastolic volume index of the true left ventricle excluding the left ventricular diverticulum at the apex was estimated as 40 mL/m2 (79% of normal left ventricle). The connection to the left ventricular cavity was narrow. (Diverticulum = left ventricular diverticulum; LV = true left ventricle.)
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Fig 2. Electrocardiogram during ventricular bigeminy; the focus of the monofocal premature ventricular contractions was thought to be located at the posteroinferior wall of the ventricle.
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The patient underwent surgical removal of this muscular-type diverticulum at 9 days of life as a treatment to control the arrythmia and to prevent rupture and thrombus formation. The diverticulum was located at the left ventricular apex with a narrow connection to the true left ventricle. The diameter was 20 mm. It was excised under cardiopulmonary bypass and cardioplegic arrest. The edge was doubly closed with a 5-0 monofilament by continuous mattress and over-and-over running suture. No thrombus was seen in the diverticulum. The posterior wall was as thin as 1 mm. Histologic examination revealed complete structure of the ventricle with three layers of endocardium, myocardium, and epicardium. However, much fibrous tissue was detected in the muscular layer. His postoperative course was uneventful and he was doing well 9 months after the operation. No PVCs occurred after the operation.
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Comment
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Although it is difficult to diagnose isolated left ventricular diverticulum because of its asymptomaticity, recent advances in diagnostic methods such as ultrasonic echocardiography make it possible even in neonates and fetuses [1], as in this case. The reported frequency of the diverticulum was 0.4% in autopsies of hearts with congenital cardiac defects [2] and 0.45% in one series of 2,000 children undergoing routine cardiac catheterization [3]. The real incidence of left ventricular diverticulum may be even greater [2–4]. However, early detection of this defect may not be helpful for early treatment, because surgical treatment is not necessary in infancy in many cases depending on the symptoms. In contrast, some authors have insisted on surgical treatment to prevent rupture and thrombus formation even in asymptomatic cases [4]. The left ventricular diverticulum is usually treated concurrently with surgical treatment for other combined anomalies such as midline thoracoabdominal defects and other cardiac anomalies. Only a few cases have been treated during infancy [5] and the diverticulum in most of those cases was combined with other anomalies.
The main indication for surgical treatment in our patient was management of PVCs, and the PVCs disappeared after the resection of the diverticulum. Some reports have described successful ventricular aneurysmectomy to treat ventricular tachycardia combined with ventricular diverticulum [3, 6]; in those reports the operation was performed in adult patients [6], for right ventricular diverticulum [3], and not for PVCs but for ventricular tachycardia. Frequent PVCs combined with cardiac failure may be an indication for surgical treatment of left ventricular diverticulum in early infancy.
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References
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- Kitchiner D., Leung M.P., Arnold R. Isolated congenital left ventricular diverticulum: echocardiographic features in a fetus. Am Heart J 1990;119:1435-1437.[Medline]
- Pressoir R., Downing J.W. Congenital diverticula of the right ventricle of the heart: a case report. J Natl Med Assoc 1980;72:262-264.[Medline]
- Hamaoka K., Onaka M., Tanaka T., Onouchi Z. Congenital ventricular aneurysm and diverticulum in children. Pediatr Cardiol 1987;8:169-175.[Medline]
- Okereke O.U.J., Cooley D.A., Frazier O.H. Congenital diverticulum of the ventricle. J Thorac Cardiovasc Surg 1986;91:208-214.[Abstract]
- Ushida N., Ohsawa M., Toyoizumi M., et al. Diverticulum of the left ventricle of the heart: Review of the literature and report of a successful removal of the diverticulum. Shinzo 1969;3:331-342.
- Shen E.N., Fukuyama O., Herre J.M., Yee E., Scheinman M.M. Ventricular tachycardia with congenital ventricular diverticulum. Chest 1991;100:283-285.[Abstract/Free Full Text]
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Abstract
Introduction
