Left ventricular (LV) diverticulum is a relatively rare condition, and it is important to differentiate it from pseudoaneurysm. The increasing use of noninvasive imaging modalities can help to demonstrate different types of ventricular outpouching structures. We report a case of congenital LV diverticulum that is much larger than the usual size and is diagnosed with tissue Doppler echocardiography and cardiac magnetic resonance imaging. Although a ventricular diverticulum is mostly asymptomatic, in the case of this particular patient, it has become complicated with infective endocarditis.  Â© 2016 Japanese College of Cardiolog

Hajsadeghi, S.

Iranpour, A.

Pazoki, M.

Talebitaher, M.

eprints Iran University of Medical Sciences

Journal of Cardiology Cases 14 (2016) 127–129Case ReportGiant congenital left ventricular diverticulum associated withinfective endocarditis: A diagnosis made by tissue DopplerechocardiographyShokoufeh Hajsadeghi (MD)a, Mahboubeh Pazoki (MD)a, Mahshid Talebitaher (MD)b,Aida Iranpour (MD)c,*aDepartment of Cardiology, Iran University of Medical Sciences, Rasool Akram General Hospital, Tehran, IranbDepartment of Infectious Disease, Iran University of Medical Sciences, Rasool Akram General Hospital, Tehran, IrancDepartment of Internal Medicine, Iran University of Medical Sciences, Rasool Akram General Hospital, Tehran, IranA R T I C L E I N F OArticle history:Received 7 March 2016Received in revised form 12 June 2016Accepted 19 June 2016Keywords:Transthoracic echocardiographyCardiac magnetic resonance imagingPseudoaneurysmA B S T R A C TLeft ventricular (LV) diverticulum is a relatively rare condition, and it is important to differentiate it frompseudoaneurysm. The increasing use of noninvasive imaging modalities can help to demonstratedifferent types of ventricular outpouching structures. We report a case of congenital LV diverticulumthat is much larger than the usual size and is diagnosed with tissue Doppler echocardiography andcardiac magnetic resonance imaging. Although a ventricular diverticulum is mostly asymptomatic, inthe case of this particular patient, it has become complicated with infective endocarditis.<Learning objective: Congenital ventricular diverticulum is a rare ﬁnding and can be diagnosed withnoninvasive imaging modalities such as tissue Doppler echocardiography and cardiac magneticresonance imaging rather than surgery. Although congenital ventricular diverticulum is asymptomaticin most cases, infective endocarditis is a known complication.> 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.Contents lists available at ScienceDirectJournal of Cardiology Casesjo u rn al ho m epag e: ww w.els evier . c om / lo cat e/ jcc as eIntroductionA diverticulum is an outpouching structure that containsendocardium, myocardium, and pericardium and has normalcontraction [1]. Unlike pseudoaneurysm, diverticulum is mostlyasymptomatic but complications such as thrombosis, embolism,rupture, and infective endocarditis can occasionally occur [1]. Here-in, we report a case of an isolated congenital left ventricular (LV)diverticulum complicated with infective endocarditis. In this article,we suggest that advanced echocardiography might be a useful toolfor the diagnosis of LV outpouching structures.Case reportThe patient was a 19-year-old girl who had been in good healthuntil she was 9 years old. At this time, she experienced fever and* Corresponding author at: Rasool Akram General Hospital, Niayesh St,Sattarkhan Ave, Tehran, Iran. Tel.: +98 2164351; fax: +98 2166517118.E-mail address: iranpouraida@gmail.com (A. Iranpour).http://dx.doi.org/10.1016/j.jccase.2016.06.0041878-5409/ 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rightschest pain for the ﬁrst time. She was evaluated in another center,and an LV outpouching, indicative of pseudoaneurysm ordiverticulum, was found fusing by echocardiography. We knowthat she had previously undergone an operation, but unfortu-nately we were not able to have full access to her medical records,and we only know that removal of the lesion was unsuccessful andshe was transferred for medical follow-up. The follow-up periodwas uneventful until one month previously, when she wasreferred to our center because of a fever. She had no history oftrauma or systemic disease, and her family history wasunremarkable.Preliminary laboratory tests revealed anemia and elevatederythrocyte sedimentation rate (115 mm/h). Multiple bloodcultures were obtained but only one was positive for methicil-lin-resistant Staphylococcus aureus. Another blood culture thattested positive for Enterobacter spp. was considered not related toinfectious endocarditis. Further evaluation revealed an opacity inthe left paracardiac space in a chest X-ray (Fig. 1), and subsequenttransthoracic echocardiography showed a mildly enlarged LV witha moderately reduced systolic function (ejection fraction = 40%)and a large outpouching (80 mm  55 mm) in the lateral side of theLV (Video 1). Tissue Doppler imaging (Fig. 2) and strain imaging reserved.Fig. 1.A postero-anterior chest X-ray revealed opacity with irregular borderand calciﬁcation in the left paracardiac space (white arrow).Fig. 2.Segmental longitudinal strain by 2D speckle tracking echocardiography;the yellow arrow shows the outer layer of left ventricular outpouching(longitudinal strain: 7%, 14%).Fig. 3.Tissue Doppler imaging; the yellow arrow shows recordable Sm(systolic tissue velocities) and the red arrow shows Em (early diastolictissue velocities) in the outer layer of left ventricular outpouching, bothof these were compatible with the presence of myocardial tissue.S. Hajsadeghi et al. / Journal of Cardiology Cases 14 (2016) 127–129128(Fig. 3) revealed synchronous contraction in the outpouching thatwas suggestive of diverticulum. Transesophageal echocardiogra-phy (TEE) was performed, which conﬁrmed the previous observa-tions. Notably, it showed smoky patterns and a linear mass with amyocardial density (36 mm  10 mm) at the opposite site of thediastolic jet of the lesion, which is suggestive of vegetation or a clot(Video 2).Supplementary video related to this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.jccase.2016.06.004.To conﬁrm whether the wall of the lesion consisted of muscle,cardiac magnetic resonance imaging (MRI) was performed.In addition to previous data, it revealed the ﬂow inside thesac with obvious muscle in its wall and no evidence of a clot(Fig. 4A and B).According to modiﬁed Duke’s criteria, our patient had onemajor criterion (intracardiac mass in the path of regurgitant jet inTEE) and three minor criteria (predisposing heart condition, fever,and one positive blood culture for a typical organism). Therefore, adiagnosis of infective endocarditis was made and empiricaltreatment with vancomycin and cefepime was started. After theresults of the blood cultures were obtained, treatment withvancomycin was continued for 6 weeks. The fever was resolved,and in follow-up echocardiography, there was no evidence ofvegetation.DiscussionOnce left ventricle outpouching lesions are detected, the nextcrucial step is to differentiate aneurysm, pseudoaneurysm, anddiverticula from each other as the prognosis and management ofeach condition is substantially different [1]. While deﬁnitediagnoses need to be made by histopathologic evaluation, areview of the literature showed that there are different clinicaland radiologic criteria for distinguishing these lesions. A recentstudy illustrated differential diagnosis of LV outpouching basedon coronary angiography, cardiac computed tomography, andcardiac MRI [2]. Among these, cardiac MRI is emerging as a usefultool that allows simultaneous anatomical and functionalevaluation of lesions [3]. Based on MRI, a pseudoaneurysm isan akinetic lesion with a narrow neck that is usually located inthe posterior or inferior parts and shows enhancement of theoverlying pericardium in viability imaging [3,4], while adiverticulum is an apical lesion with a variable neck size(usually narrow) and synchronous contractility with no en-hancement in the wall of the sac or pericardium in viabilityimaging [3,5]. The size of diverticula may vary from as small as0.5 cm in diameter to as large as 8–9 cm [6]. Tissue Doppler,strain, and strain rate echocardiography provide additionalinformation in comparison to conventional echocardiography;these techniques also provide a means of assessing wallmotion [7].Our patient was subjected to tissue Doppler imaging, strainimaging, and 3-dimensional TTE, and as shown in Figs. 2 and 3,we found contractile function in the outpouching that wassuggestive of a diverticulum. In addition to TTE, there wereother clues in the history and imaging that conﬁrmed ourdiagnosis; a narrow neck lesion with a thin ﬁbrous layer andthe absence of a clot, an uneventful period of about 10 years sincethe ﬁrst presentation, and a lack of previous history ofany insulting factor to the heart were all suggestive of adiverticulum.In conclusion, we aimed to show that a diverticulum can be alarge lesion, and although they are mostly asymptomatic, they canbe complicated with infective endocarditis.Fig. 4.Multiplanar magnetic resonance imaging (panel A: coronal image, panel B: vertical long-axis image) shows large left ventricular (LV) outpouching measuring76 mm  50 mm (yellow arrow), which contains a thin myocardium and is connected to a mid LV lateral segment via a narrow neck (white arrow). LA, left atrium;RA, right atrium; RV, right ventricle.S. Hajsadeghi et al. / Journal of Cardiology Cases 14 (2016) 127–129 129Conﬂict of interestThe authors declare that they have no conﬂicts of interest.References[1] Makkuni P, Kotler MN, Figueredo VM. Diverticular and aneurysmal structures ofthe left ventricle in adults; report of a case within the context of a literaturereview. Tex Heart Inst J 2010;37:699–705.[2] Romagnoli A, Ricci A, Morosetti D, Fusco A, Citraro D, Simonetti G. Congenitalleft ventricular diverticulum. Multimodality imaging evaluation and literaturereview. J Saudi Heart Assoc 2015;27:61–7.[3] Sharma A, Kumar S. Overview of left ventricular outpouchings on cardiacmagnetic resonance imaging. Cardiovasc Diagn Ther 2015;5:464–70.[4] Konen E, Merchant N, Gutierrez C, Provost Y, Mickleborough L, Paul NS, Butany J.True versus false left ventricular aneurysm: differentiation with MR imaging –initial experience. Radiology 2005;236:65–70.[5] Srichai MB, Hecht EM, Kim DC, Jacobs JE. Ventricular diverticula on cardiac CT:more common than previously thought. AJR Am J Roentgenol 2007;189:204–8.[6] Ohlow MA. Congenital left ventricular aneurysms and diverticula: deﬁnition,pathophysiology, clinical relevance and treatment. Cardiology 2006;106:63–72.[7] Pellerin D, Sharma R, Elliott P, Veyrat C. Tissue Doppler, strain, and strain rateechocardiography for the assessment of left and right systolic ventricularfunction. Heart 2003;89:iii9–17.

Giant congenital left ventricular diverticulum associated with infective endocarditis: A diagnosis made by tissue Doppler echocardiography

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Giant congenital left ventricular diverticulum associated with infective endocarditis: A diagnosis made by tissue Doppler echocardiography

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