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Case Report

Case Report: Congenital left ventricular diverticulum: a pediatric case report

[version 1; peer review: 2 approved with reservations]
PUBLISHED 03 Nov 2016
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Abstract

Congenital left ventricular diverticulum is a rare cardiac abnormality consisting of a localized outpouching from the free wall of the cardiac chamber. It is usually asymptomatic. However, complications such as infective endocarditis, arrhythmias, and embolism may occur. Medical ultrasound, echocardiography, CT angiography, MRI and invasive ventriculography are diagnostic tools used to identify congenital left ventricular diverticulum. Surgical resection is the treatment of choice in symptomatic patients, whereas the management of asymptomatic patients often represents a therapeutic dilemma. We report the case of a symptomatic left ventricular diverticulum on a 3-day-old female with Cantrell’s syndrome treated surgically. Postoperative course was uneventful. The patient was discharged with a good clinical condition. The prognosis of this malformation is poor if not diagnosed in the perinatal period. A diagnosis can be suspected with echocardiography; however, a CT scan allows a complete study of the problem. The treatment is always surgical with a good postoperative prognosis.

Keywords

CT angiography, MRI, left ventriculum, echocardiography

Introduction

Congenital left ventricular diverticulum is a rare cardiac abnormality, consisting of a localized out pouching from the free wall of the cardiac chamber. Commonly, this is from the left ventricular apex; however, non-apical diverticula may also occur1. There are two types of ventricular diverticulum: muscular or fibrotic2.

Ventricular diverticulum is usually associated with a thoracoabdominal wall defect as seen in the spectrum of Cantrell’s pentalogy1,2. Cantrell’s syndrome is a very rare congenital disease, described by Cantrell, Haller, and Ravitch in 1958, associating a lower sternal defect, a supraumbilical abdominal wall defect, a deficiency of the anterior portion of the diaphragm, a deficiency in the diaphragmatic portion of the pericardium, and cardiac malformations3.

This study reports a rare case of a left ventricular diverticulum on a new born infant with Cantrell’s syndrome.

Case report

A 3-day-new born African female, resulting from an irregularly monitored pregnancy, was referred to the Department of Pediatric Surgery of la Rabta Hospital of Tunisia for the investigation of an umbilical mass measuring 3cm in diameter. The baby was the first child of parents with no history of familial disease, and there was no significant antenatal history. Clinical examination showed a well-looking infant, presenting with a pulsatile mass with a palpable thrill in concordance with cardiac contractions. An electrocardiogram showed a normal sinus rhythm (150bpm) with a right deviation of the QRS axis and right ventricle hypertrophy signs.

Echocardiography showed a normal left ventricle with conserved contractility. Important dilatation of the right ventricle and a ventricular septum defect were seen. Both the aorta and pulmonary artery arose from the right ventricle, and the pulmonary artery was posterior to the aorta (Figure 1). Abnormal flow was seen in the cardiac apex.

1596f1c5-8ebf-426a-8e69-c707dad97e32_figure1.gif

Figure 1. Congenital left ventricular diverticulum on echocardiography.

Echocardiography showing abnormal flow in the left ventricle apex.

A 64-channel multi-detector CT (GE LightSpeed VCT) was performed for additional characterization. Sedation of the infant was not necessary. Thoracoabdominal helicoidal acquisition after the injection of non-ionic contrast agent was realized in a cranio caudal direction. The contrast enhanced multi-slice CT showed a thin walled channel extending up from the left ventricular apex to the anterior abdominal wall (Figure 2). This diverticulum was 6cm long following the abdominal midline through a defect of the anterior diaphragm and extending up to the umbilical region (Figure 3).

1596f1c5-8ebf-426a-8e69-c707dad97e32_figure2.gif

Figure 2. Diagnosis of congenital left ventricular diverticulum on CT scan.

Volume rendered 3D CT image showing a diverticulum originating from the left ventricle free wall.

1596f1c5-8ebf-426a-8e69-c707dad97e32_figure3.gif

Figure 3. Extent of congenital left ventricular diverticulum on CT scan.

Mid-sagittal maximum intensity projection (MIP) thin CT image shows the diverticulum extending up to the umbilical region.

Myocardial thickness of the outpouching was 3mm (Figure 4A). No herniating bowels were seen (Figure 4B). The examination did not show any other abnormality of intra abdominal organs.

1596f1c5-8ebf-426a-8e69-c707dad97e32_figure4.gif

Figure 4. Diagnosis of congenital left ventricular diverticulum associated with the defect of the anterior abdominal wall on CT scan.

(A) Axial maximum intensity projection (MIP) CTscan showing the diverticulum wall consisting of a 3mm thick myocardium. (B) Axial enhanced multiple detector CT shows the defect of the anterior abdominal wall without herniating bowels.

The multi detector CT scan also confirmed the dextro transposition of the aorta and pulmonary artery (Figure 5) and the ventricular septum defect.

Surgical treatment was decided upon. The patient was connected to cardiopulmonary bypass and the diverticulum was opened and resected. The entry site was obliterated with a polytetrafluoroethylene patch. Further inspection revealed a normal-sized left ventricle and normal-sized coronary arteries, with no coronary aneurysms. Overlapping reconstruction of the abdominal anterior wall and diaphragm defects were also performed without using any prosthetic material.

1596f1c5-8ebf-426a-8e69-c707dad97e32_figure5.gif

Figure 5. Diagnosis of dextro transposition of the great vessels associated with congenital left ventricular diverticulum on CT scan.

Volume rendered 3D CT image showing the dextro transposition of the great vessels.

The postoperative period was uneventful, and the child was discharged from the hospital on the sixth postoperative day. We proposed medical management for our patient, comprising aspirin at a dosage of 5mg/kg/day to prevent any thromboembolic situation.

At a 6 month follow-up examination, the infant had a good clinical condition and a normal cardiac function on echocardiography.

Discussion

Congenital left ventricular diverticulum is a rare cardiac malformation. Its incidence has been reported to be approximately 0.04% in the general population and approximately 0.02% in a consecutive pediatric autopsy series2,4. Although ventricular diverticulum may exist alone, it can also be associated with cardiac, vascular, or thoracoabdominal abnormalities46. In fact, cardiovsacular desease is a component of Cantrell’s pentalogy in some patients3. Cantrell’s pentalogy consists of a defect in the lower sternum, a supra umbilical abdominal wall defect, a deficiency of the anterior portion of the diaphragm, a deficiency in the diaphragmatic portion of the pericardium, and a congenital heart defect2.

Patients with isolated cardiac diverticulum are usually asymptomatic; however, there are reports associated with arrhythmias, embolic events, and even death due to diverticulum rupture2. Spontaneous rupture occurs very frequently, and can be explained by an increase in pressure inside the diverticulum as a result of a difference in the phase of contraction between the left ventricle and the diverticulum7.

Patients with a diverticulum sometimes present with an abnormal electrocardiogram8,9. In the case of our patient, a right deviation of the QRS axis and right ventricle hypertrophy signs were noted. Accurate diagnosis cans be made with ultra sonography or echocardiography210, and prenatal diagnostics have been reported in the literature5. CT angiography, MRI and invasive ventriculography give a clearer picture of the problem1,11. In the case of our patient, the diagnosis was suspected on echocardiography, and the CT angiography allowed a complete study of the pathology and confirmed the association with other cardiac, diaphragmatic and abdominal abnormalities. Surgical treatment is usually recommended when left ventricular diverticulum is associated with other cardiac or abdominal abnormalities. Perioperative management requests a multidisciplinary experienced team, due to the complexity of cardiac and thoraco abdominal abnormalities associated in Cantrell’s syndrome7. Recently, the field of percutaneous correction for congenital left ventricular diverticulum has witnessed tremendous development and a percutaneous transcatheter device treatment was reported12.

The strength of our study is the completeness of the observation with a 6 month follow-up. However, the limitation of our case is the absence of the full perioperative findings.

In conclusion, congenital left ventricular diverticulum is a rare cardiac malformation. The prognosis of this malformation is poor if not diagnosed in the perinatal period. Complications, such as embolism, infective endocarditis, arrhythmia and, rarely, rupture can occur. Although it may exist alone, it can also be associated with cardiac, vascular, or thoracoabdominal abnormalities (e.g., Cantrell’s syndrome). A diagnosis can be suspected with echocardiography. CT angiography allow a complete study of the problem. The treatment is always surgical with good postoperative prognosis.

Consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the parent of the patient.

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Jrad M, Affes M, Behi S et al. Case Report: Congenital left ventricular diverticulum: a pediatric case report [version 1; peer review: 2 approved with reservations]. F1000Research 2016, 5:2628 (https://doi.org/10.12688/f1000research.9936.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
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PUBLISHED 03 Nov 2016
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Reviewer Report 29 Dec 2016
Ilya Soynov, Department of Pediatric Cardiac Surgery, Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russian Federation 
Approved with Reservations
VIEWS 8
This case is very interesting because of the combination Cantrell’s pentalogy and transposition of great arteries is extremely rare.

But there are several questions to the authors.
  • I have a doubt of the
... Continue reading
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CITE
HOW TO CITE THIS REPORT
Soynov I. Reviewer Report For: Case Report: Congenital left ventricular diverticulum: a pediatric case report [version 1; peer review: 2 approved with reservations]. F1000Research 2016, 5:2628 (https://doi.org/10.5256/f1000research.10707.r18844)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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15
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Reviewer Report 18 Nov 2016
Mazeni Alwi, Department of Paediatric Cardiology, Institut Jantung Negara, Kuala Lumpur, Malaysia 
Approved with Reservations
VIEWS 15
This is an interesting case report of congenital LV diverticulum in the setting of Cantrell’s syndrome. The authors describe well the clinical findings and imaging techniques with echocardiography of MDCT and contrast angiography which confirmed the diagnosis. Advances in non-invasive ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Alwi M. Reviewer Report For: Case Report: Congenital left ventricular diverticulum: a pediatric case report [version 1; peer review: 2 approved with reservations]. F1000Research 2016, 5:2628 (https://doi.org/10.5256/f1000research.10707.r17737)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 21 Nov 2016
    Myriam Jrad, Department of Radiology, La Rabta Hospital, Tunis, Tunisia
    21 Nov 2016
    Author Response
    Firstly, thank you for your interesting comments.
    Indeed, given the heaviness of the operation and the lack of means of anesthesia in our department at this age the abnormality of ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 21 Nov 2016
    Myriam Jrad, Department of Radiology, La Rabta Hospital, Tunis, Tunisia
    21 Nov 2016
    Author Response
    Firstly, thank you for your interesting comments.
    Indeed, given the heaviness of the operation and the lack of means of anesthesia in our department at this age the abnormality of ... Continue reading

Comments on this article Comments (0)

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VERSION 1 PUBLISHED 03 Nov 2016
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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