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Congenital isolated biventricular diverticula evaluated by cardiac computed tomography and magnetic resonance imaging
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Congenital Isolated Biventricular Diverticula Evaluated by Cardiac Computed Tomography and Magnetic Resonance Imaging Satoshi Okayama, MD, Shiro Uemura, MD ∗ , Tunenari Soeda, MD, Ayako Seno, MD, Kenji Onoue, MD, Ken-ichi Ishigami, MD, Manabu Horii, MD and Yoshihiko Saito, MD, PhD First Department of Internal Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
A
51-year-old woman with a history of smoking and dyslipidaemia was referred to our department with atypical chest pain, blood pressure of 132/82 mmHg, a regular pulse of 82 bpm, no audible cardiac murmur and clear lungs. Electrocardiography showed a normal sinus rhythm without specific ST-segment changes. Cardiac computed tomography (CT) due to suspected coronary artery disease revealed small dimpled and outpouching lesions at the apex of the left and right ventricles, respectively, with no significant stenosis of the proximal coronary arteries. The right ventricular outpouching lesion connected with the right ventricle through a narrow neck (Fig. 1A and B). These biventricular lesions and the other cardiac chamber did not contain any obvious thrombus (Fig. 1C–F). We suspected that the lesions were congenital isolated biventricular diverticula, but small apical aneurysms after myocardial infarction could not be ruled out because cardiac CT sometimes poorly visualises distal small coronary arteries. A more detailed examination of myocardial tissue and motion proceeded using cardiac magnetic resonance imaging (MRI), because echocardiography could not evaluate the apex and right ventricle due to a poor window. Cine imaging demonstrated normal left and right ventricular wall motion and that both the left ventricular dimpled (Fig. 2A and B) and right ventricular outpouching (Fig. 2D and E) lesions synchronously contracted with the left and right ventricle, respectively. No other cardiac malformations were evident. Delayed gadoliniumenhanced imaging revealed that the thickness of the left and right ventricular myocardium including these lesions
was normal, and this together with the absence of myocardial fibrosis suggested no previous myocardial infarction or inflammation (Fig. 2C and F). These findings indicated congenital isolated biventricular diverticula and not aneurysms after myocardial infarction. The diverticula were not surgically resected because the patient had no associated symptoms and follow-up showed that the frequency of atypical chest pain decreased after she stopped smoking. Congenital isolated ventricular diverticulum is a cardiac malformation that arises more often from the left ventricle, and rarely from the right or both ventricles [1,2]. Although the prevalence has been considered very low (0.04–0.4%), a recent study using cardiac CT revealed a higher prevalence (2.2%) [3]. The accurate diagnosis of congenital isolated biventricular diverticula requires differentiation from other conditions, such as aneurysm after myocardial infarction or involvement of other cardiac malformations such as Cantrell syndrome, ventricular septal defect, and tetralogy of Fallot. Moreover, complications of thrombus in the diverticulum should be considered [4]. The combination of cardiac CT and MRI was useful for the non-invasive evaluation of detailed anatomical structures as well as of comorbid cardiac conditions in this patient. To the best of our knowledge, this is the first description of a non-invasive evaluation of congenital isolated biventricular diverticula using cardiac CT combined with MRI. Our findings suggest that evaluation by combined cardiac CT and MRI is useful for the accurate diagnosis of congenital isolated biventricular diverticula.
Received 16 August 2009; received in revised form 19 December 2009; accepted 9 February 2010; available online 10 May 2010 ∗ Corresponding author. Tel.: +81 74 422 3051; fax: +81 74 422 9726. E-mail address: [email protected] (S. Uemura).
1443-9506/04/$36.00 doi:10.1016/j.hlc.2010.02.005
Okayama et al. Image
631 IMAGE
Heart, Lung and Circulation 2010;19:630–632
Fig. 1. Volume rendering reconstruction (A) and maximal intensity projection reconstruction (B) of cardiac computed tomograms. Small dimple (black arrow) and outpouching (white arrow) lesions at apex of left and right ventricle, respectively. Multiplanar reconstruction shows no obvious thrombus in left (C and D, black arrow) and right (E and F, white arrow) ventricular lesions, respectively. RCA, right coronary artery; LAD, left anterior descending artery; LCX, left circumflex coronary artery; RV, right ventricle; LV, left ventricle.
Fig. 2. Cardiac magnetic resonance cine images at diastole (A and D) and at systole (B and E). Left and right ventricular wall motion is normal. Left ventricular dimpled (black arrow) and right ventricular outpouching (white arrow) lesions synchronously contract with left and right ventricles, respectively. Delayed gadolinium-enhanced image (C and F) shows that thickness of biventricular myocardium including left (black arrow) and right (white arrow) lesions is normal and myocardial fibrosis is absent.
632 IMAGE
Okayama et al. Image
Heart, Lung and Circulation 2010;19:630–632
Acknowledgment
[3] 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. [4] Parthenakis FI, Kochiadakis GE, Patrianakos AP, Hamilos MI, Mitrouska I, Katsamouris AN, Vardas PE. Peripheral arterial embolism due to a left ventricular diverticulum in a young adult. Chest 2005;127:1452–4.
The authors received no external financial support.
References [1] Okereke OU, Cooley DA, Frazier OH. Congenital diverticulum of the ventricle. J Thorac Cardiovasc Surg 1986;91:208–14. [2] Walton-Shirley M, Smith SM, Talley JD. Left ventricular diverticulum: case report and review of the literature. Cathet Cardiovasc Diagn 1992;26:31–3.
Image
Congenital Isolated Biventricular Diverticula Evaluated by Cardiac Computed Tomography and Magnetic Resonance Imaging Satoshi Okayama, MD, Shiro Uemura, MD ∗ , Tunenari Soeda, MD, Ayako Seno, MD, Kenji Onoue, MD, Ken-ichi Ishigami, MD, Manabu Horii, MD and Yoshihiko Saito, MD, PhD First Department of Internal Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan
A
51-year-old woman with a history of smoking and dyslipidaemia was referred to our department with atypical chest pain, blood pressure of 132/82 mmHg, a regular pulse of 82 bpm, no audible cardiac murmur and clear lungs. Electrocardiography showed a normal sinus rhythm without specific ST-segment changes. Cardiac computed tomography (CT) due to suspected coronary artery disease revealed small dimpled and outpouching lesions at the apex of the left and right ventricles, respectively, with no significant stenosis of the proximal coronary arteries. The right ventricular outpouching lesion connected with the right ventricle through a narrow neck (Fig. 1A and B). These biventricular lesions and the other cardiac chamber did not contain any obvious thrombus (Fig. 1C–F). We suspected that the lesions were congenital isolated biventricular diverticula, but small apical aneurysms after myocardial infarction could not be ruled out because cardiac CT sometimes poorly visualises distal small coronary arteries. A more detailed examination of myocardial tissue and motion proceeded using cardiac magnetic resonance imaging (MRI), because echocardiography could not evaluate the apex and right ventricle due to a poor window. Cine imaging demonstrated normal left and right ventricular wall motion and that both the left ventricular dimpled (Fig. 2A and B) and right ventricular outpouching (Fig. 2D and E) lesions synchronously contracted with the left and right ventricle, respectively. No other cardiac malformations were evident. Delayed gadoliniumenhanced imaging revealed that the thickness of the left and right ventricular myocardium including these lesions
was normal, and this together with the absence of myocardial fibrosis suggested no previous myocardial infarction or inflammation (Fig. 2C and F). These findings indicated congenital isolated biventricular diverticula and not aneurysms after myocardial infarction. The diverticula were not surgically resected because the patient had no associated symptoms and follow-up showed that the frequency of atypical chest pain decreased after she stopped smoking. Congenital isolated ventricular diverticulum is a cardiac malformation that arises more often from the left ventricle, and rarely from the right or both ventricles [1,2]. Although the prevalence has been considered very low (0.04–0.4%), a recent study using cardiac CT revealed a higher prevalence (2.2%) [3]. The accurate diagnosis of congenital isolated biventricular diverticula requires differentiation from other conditions, such as aneurysm after myocardial infarction or involvement of other cardiac malformations such as Cantrell syndrome, ventricular septal defect, and tetralogy of Fallot. Moreover, complications of thrombus in the diverticulum should be considered [4]. The combination of cardiac CT and MRI was useful for the non-invasive evaluation of detailed anatomical structures as well as of comorbid cardiac conditions in this patient. To the best of our knowledge, this is the first description of a non-invasive evaluation of congenital isolated biventricular diverticula using cardiac CT combined with MRI. Our findings suggest that evaluation by combined cardiac CT and MRI is useful for the accurate diagnosis of congenital isolated biventricular diverticula.
Received 16 August 2009; received in revised form 19 December 2009; accepted 9 February 2010; available online 10 May 2010 ∗ Corresponding author. Tel.: +81 74 422 3051; fax: +81 74 422 9726. E-mail address: [email protected] (S. Uemura).
1443-9506/04/$36.00 doi:10.1016/j.hlc.2010.02.005
Okayama et al. Image
631 IMAGE
Heart, Lung and Circulation 2010;19:630–632
Fig. 1. Volume rendering reconstruction (A) and maximal intensity projection reconstruction (B) of cardiac computed tomograms. Small dimple (black arrow) and outpouching (white arrow) lesions at apex of left and right ventricle, respectively. Multiplanar reconstruction shows no obvious thrombus in left (C and D, black arrow) and right (E and F, white arrow) ventricular lesions, respectively. RCA, right coronary artery; LAD, left anterior descending artery; LCX, left circumflex coronary artery; RV, right ventricle; LV, left ventricle.
Fig. 2. Cardiac magnetic resonance cine images at diastole (A and D) and at systole (B and E). Left and right ventricular wall motion is normal. Left ventricular dimpled (black arrow) and right ventricular outpouching (white arrow) lesions synchronously contract with left and right ventricles, respectively. Delayed gadolinium-enhanced image (C and F) shows that thickness of biventricular myocardium including left (black arrow) and right (white arrow) lesions is normal and myocardial fibrosis is absent.
632 IMAGE
Okayama et al. Image
Heart, Lung and Circulation 2010;19:630–632
Acknowledgment
[3] 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. [4] Parthenakis FI, Kochiadakis GE, Patrianakos AP, Hamilos MI, Mitrouska I, Katsamouris AN, Vardas PE. Peripheral arterial embolism due to a left ventricular diverticulum in a young adult. Chest 2005;127:1452–4.
The authors received no external financial support.
References [1] Okereke OU, Cooley DA, Frazier OH. Congenital diverticulum of the ventricle. J Thorac Cardiovasc Surg 1986;91:208–14. [2] Walton-Shirley M, Smith SM, Talley JD. Left ventricular diverticulum: case report and review of the literature. Cathet Cardiovasc Diagn 1992;26:31–3.