Images in cardiovascular medicine. Cantrell's syndrome: left ventricular diverticulum in an adult patient

A case report: multiple right ventricular diverticula with constrictive pericarditis and right heart failure

Background

Right ventricular diverticula (RVD) are very rare congenital anomalies and their association with constrictive pericarditis is even rarer. So far, only one case has been published in literature.

Case summary

We report a case of multiple congenital RVD with constrictive pericarditis and right heart failure which was incidentally identified on surveillance computed tomography (CT) for abdominal lymphangioma. Interval CT, echocardiography, and cardiac magnetic resonance imaging (CMR) studies were performed and reviewed. Computed tomography abdomen showed hepatic congestion with features of portal hypertension, increasing size of the RVD on review of serial CTs, and eccentric foci of pericardial calcification. Echocardiography performed for breathlessness demonstrated supranormal early diastolic tissue velocities with average of 19.8 cms⁻¹ and a septal bounce phenomenon on m-mode imaging suggesting constrictive physiology, which triggered a CMR referral. Cardiac magnetic resonance imaging HASTE and right ventricular (RV) outflow tract imaging showed four outpouchings along RV free wall, the largest measuring 4.5 × 2 cm with a sizeable neck. These outpouchings displayed a trabecular network and/or were contractile aiding the diagnosis of diverticula as opposed to aneurysms. Right ventricular function was moderately compromised, whereas left ventricular function was preserved.

Discussion

Right ventricular diverticula can be associated with, and potentially be causative of, pericardial thickening and calcification eventually leading to constrictive pericarditis and heart failure.

An unfortunate case of subaortic left ventricular diverticulum

A 38-year-old man presented with exertional angina of 1-year duration. Treadmill was strongly positive. Coronary angiogram revealed a significant phasic systolic compression of the left main and the proximal left circumflex artery. Echo and MRI revealed a subaortic left ventricle diverticulum causing compression of the coronary vessels. Before the planned surgery, the patient had sudden deterioration with cardiogenic shock and could not be saved.

Prognostic role of isolated left ventricular diverticuli detected by cardiovascular magnetic resonance

BACKGROUND

Isolated left ventricular diverticulum, a rare cardiac malformation, can be asymptomatic or associated with systemic embolization, ventricular arrhythmias, or sudden death. MRI allows for the detection of diverticuli and the distinction between fibrous and muscular types using the delayed enhancement technique.

AIM

To evaluate the prevalence of left ventricular diverticuli in nonselected consecutive patients who had undergone MRI.

METHODS

In a total of 3273 consecutive patients who had undergone cardiac magnetic resonance from January 2001 to December 2005, isolated ventricular diverticuli were found in 25 patients (0.76%), with no apparent cardiac disease. A delayed enhancement technique was used to distinguish fibrous and muscular types. The prevalence of complications was evaluated with a follow-up of 52 ± 8 months.

RESULTS

The site of the left ventricular diverticuli was the septum in 10 (37%) cases, inferior wall in 6 (22%) cases, lateral wall in 4 (15%) cases, and apical in 7 (26%) cases. In two cases, multiple diverticuli were found. In delayed enhancement images, a partial or total fibrous diverticulum was found in 6 (24%) patients. At follow-up, clinical complications were recorded in 6 (24%) patients; 2 (8%) patients had arrhythmic complications and 4 (12%) patients had embolic complications of presumed cardiac origin. In addition, two patients (8%) had nonsustained ventricular tachycardia diagnosed using 24-h ECG Holter monitoring. Fibrous type diverticuli were associated with a higher incidence of arrhythmic complications than the muscular type.

CONCLUSION

The prevalence of isolated ventricular diverticuli detected by MRI is higher than that previously reported with other imaging techniques. Fibrous diverticuli are associated with a higher incidence of arrhythmic complications.

Chest Pain With Apical Diverticulum in the Absence of Coronary Disease: Case Report and Review of the Literature

Aneurysmal dilatation of segment of the left ventricle in the absence of coronary disease has been reported and termed diverticulum, which appears to be a congenital anomaly. A 56-year-old white female was admitted to our hospital with chest pain that has been intermittent over the past 1 month. The pain was described as exertional, substernal and pressure-like in quality, radiating to left arm and jaw, and lasting approximately 30 minutes each episode; it was associated with shortness of breath. She has had approximately 10 such episodes in the past 1 month. The patient denied any dizziness, palpitations, syncope, orthopnea or paroxysmal nocturnal dyspnea (PND). She has had a history of hypertension for many years, however has not been compliant with her medications for the past 6 months. On admission, vital signs revealed blood pressure of 185/100 mm Hg, and regular heart rate of 94 beats per minute. Physical examination revealed a normal body habitus. Cardiac examination revealed no murmurs or extra cardiac sounds on auscultation. The pulmonary and abdomen examinations were unremarkable. The chest radiograph was normal. The electrocardiogram showed sinus rhythm, with borderline prolongation of the QT interval. The laboratory test results, including cardiac enzymes, were normal. Transthoracic echocardiography (TTE) revealed normal left ventricular systolic function, with localized dyskinesis of the apex. No significant valvular abnormalities were identified. Coronary angiography revealed angiographically normal coronary arteries; left ventriculography showed abnormal apical "filling defect" consistent with an aneurysm. A repeat echocardiogram using Definity contrast revealed left ventricular apical diverticulum with hypertrabeculation. The patient was placed on antihypertensive medications with resolution of her chest pain, and was able to ambulate comfortably. The patient was counseled thoroughly on the importance of compliance with her medications. This case describes an apical left ventricular diverticulum found incidentally and demonstrated on contrast echocardiography in a patient with chest pain.

Characteristics and outcome of congenital left ventricular aneurysm and diverticulum: Analysis of 809 cases published since 1816

BACKGROUND

Congenital left ventricular aneurysm (LVA) or diverticulum (LVD) is rare cardiac anomalies. We aimed to analyse the clinical characteristics and outcome in all ever published patients.

METHODS

MEDLINE, Web of science, Google and EMBASE, and reference lists of relevant articles were searched for publications reporting on LVA or LVD patients.

RESULTS

We identified 809 patients published since 1816 [354 (49.1%) LVA, 453 (50.6%) LVD, 2 (0.3%) both]. Mean age at diagnosis was 34.1±27 (LVA) and 29.7±27.6years (LVD; p=0.05). 48.9% were male. LVA was larger (38.7±22.5mm versus 31.4±21.2mm; p=0.002) and frequently found in submitral location (33% versus 4.9%; p<0.001), LVD was frequently located at the LV-apex (61.2% versus 28.7%; p<0.001). LVD was often associated with cardiac (34.2% versus 11%; p<0.001) or extracardiac anomalies (32.7% versus 3%; p<0.001). LVA patients presented more frequently with ventricular tachycardia/fibrillation (18.1% versus 13.1%; p=0.01), the incidences of rupture (4% versus 4.5%; p=0.9), syncope (8.3% versus 5.1%; p=0.1), and embolic events (4.9% versus 3.6%; p=0.4) at presentation were not different between LVA and LVD. Mean follow-up was 56.3±43months. Cardiac death occurred more frequently in the LVA group (11.5% versus 5.0%; p=0.05) at a median age of 0.8 [LVA] and 2.5 [LVD] years. The leading cause of cardiac death was congestive heart failure in the LVA-group (50.0% versus 0.0%; p=0.01), and rupture in the LVD-group (75.0% versus 27.3%; p=0.04).

CONCLUSIONS

LVA and LVD are distinct congenital anomalies with different clinical and morphological characteristics. The prognosis of LVA is significantly worse during long-term follow-up.

Pentalogy of Cantrell with Ectopia Cordis: CT Findings

A 14-month-old girl with pentalogy of Cantrell, a very rare congenital syndrome characterized by an epigastric omphalocele and malformations of the heart, sternum, pericardium, and diaphragm, underwent echocardiography and multidetector computed tomography before surgical repair of these deformities was attempted. These tests revealed multiple cardiovascular and noncardiovascular abnormalities. After surgery, the patient's cardiovascular status was stable. Although studies have shown that echocardiography, multidetector computed tomography, and magnetic resonance imaging may each play a role in the diagnosis and management of this condition, there are few data available to support the use of one imaging modality over another.

Ectopia cordis with a double outlet right ventricle, large ventricular septal defect, malposed great arteries and left ventricular hypoplasia

Ectopia cordis, defined as partial or complete displacement of the heart outside of the thoracic cavity, is a rare congenital malformation. If not surgically corrected during the early years of life, ectopia cordis can prove to be a fatal abnormality. However, due to the presence of multiple intracardiac and extracardiac malformations, a corrective surgery might not always be successful. The pathology of ectopia cordis with a double outlet right ventricle, large ventricular septal defect, malposed great arteries and left ventricular hypoplasia is discussed, highlighting the complexities involved in such a rare disorder.

Ectopia cordis: a rare congenital anomaly

Ectopia cordis (EC) is a rare congenital anomaly associated with the heart positioned outside of the thoracic cavity either partially or completely. The ectopic heart can be found along a spectrum of anatomical locations, including the cervical, thoracic and abdominal regions and in most cases, it protrudes outside the chest through a split sternum. Although the first case of EC was identified during the early 1600s only 91 cases have been reported since then in the literature. This review will discuss the history and prevalence of EC, its etiology, morphology, presentation and symptoms, complications, diagnosis, treatment and management and prognosis.

[Isolated left ventricular congenital diverticulum in adult: Report of cardiac imaging]

Cardiac diverticulum is an infrequent congenital malformation, it's even more rare in adulthood. It's often associated with other thoraco-abdominal diverticulums, and rarely isolated. The diagnosis relies on echocardiography. By the way, the magnetic resonance imagery (MRI) allows a finer analysis of the diverticulum, its topography and its situation contributed to vascular and cardiac structures, it has largely replaced the ventriculography. We report in this article the case of a patient of 36 years whose diagnosis of the diverticulum was made by transthoracic echocardiography (TTE) at the time of an assessment of dyspnea, this exam also objectified a mitral insufficiency by deformation and dilatation of the mitral annulus. Radiological assessment was completed by a transoesophageal echocardiography (TOE) and magnetic resonance imagery (MRI). Surgical treatment consisted of surgical closing of the diverticulum and mitral annuloplasty.

Spectrum of Cantrell's pentalogy: case series from a single tertiary care center and review of the literature

The pentalogy of Cantrell (PC) was first described in 1958. It includes five anomalies: a deficiency of the anterior diaphragm, a midline supraumbilical abdominal wall defect, a defect in the diaphragmatic pericardium, various congenital intracardiac abnormalities, and a defect of the lower sternum. Five patients showing the PC spectrum are reported. The report presents the prenatal diagnosis, the postnatal course, and the patients' outcome at a tertiary care center from June 2001 to May 2012. A literature review and the management plan for this group of patients also are discussed. All patient data were obtained via electronic medical records retrospectively after approval by the institutional review board at the home institution. The patients in the study were three males and two females. For all of the patients, a prenatal diagnosis had been determined. The mean gestational age at delivery was 36.6 weeks. One patient had associated cranial and spine malformations. All the patients had associated congenital heart disease but a normal karyotype. Four of the five patients died in the first year of life. The ages at death ranged from 0 to 259 days (mean, 46.2 ± 51.8 days). The patients who did not survive had withdrawal of care due to increased morbidity, associated complications, or parental wishes. The pentalogy of Cantrell is a wide spectrum of associations. Patients with the complete PC together with complex congenital heart disease or extracardiac malformations may have a poor prognosis. Incomplete PC cases may have a better outcome based on associated anomalies. Prenatal counseling plays a very important role in the decision-making process for the families and has a significant impact on the postnatal management. A multidisciplinary team approach is essential for successful postpartum outcomes.

Computed tomographic features of congenital left ventricular diverticulum

Congenital left ventricular diverticulum is a rare cardiac malformation characterized by a localized out-pouching from the cardiac chamber. They are most often found in the left ventricle (LV) but have been reported to occur in all chambers of the heart. The patient is usually asymptomatic. However, complications like embolism, infective endocarditis, arrhythmia and, rarely, rupture may be the initial presentation. Diagnosis can be established by echocardiography (EKG), computed tomographic (CT) angiography, and magnetic resonance imaging (MRI). We report a case of congenital left ventricular diverticulum in an adult with no valvular abnormality as an incidental finding in an uncommon location.

Double-chambered left ventricle in an asymptomatic adult patient

This article shows a case of double-chambered left ventricle in asymptomatic 60-year-old man. This rare congenital entity is usually diagnosed in the neonatal or paediatric age, and it is characterized by the subdivision of the left ventricle in two chambers by an abnormal septum or muscle band. Differential diagnosis includes two other congenital left ventricular (LV) outpouching entities, such as diverticulum and aneurysm. As shown in our case, double-chambered left ventricle exhibits mixed features. A comprehensive cardiovascular magnetic imaging study is useful in the distinction of these closely related congenital diseases and, therefore, important for the correct final diagnosis.

Prognosis of pentalogy of Cantrell depends mainly on the severity of the intracardiac anomalies and associated malformations

We believe the paper may be of particular interest to the readers of your journal. It is a commentary on van Hoorn et al: Pentalogy of Cantrell: two patients and a review to determine prognostic factors for optimal approach (Eur J Pediatr (2008) 167:29-35). The correct definition of pentalogy of Cantrell and ectopia cordis was described in the text and the determinant factor that affects the prognosis of pentalogy of Cantrell was discussed.

Double-outlet right ventricle in a neonate with Cantrell's syndrome

We report a case of the association of Cantrell's syndrome with double-outlet right ventricle in a neonate.

Multiple left ventricular diverticuli in an asymptomatic adult: Case report and review of the literature

Left ventricular (LV) diverticulum is a rare congenital abnormality for which the etiology, management, and natural history are very poorly understood. Although most often observed as a single diverticulum, we report a case of multiple LV diverticuli in an asymptomatic adult referred for coronary evaluation due to an abnormal electrocardiogram. LV diverticuli are often associated with other congenital malformations, but can also be found in isolation. Cardiac magnetic resonance imaging provides enhanced ability to determine size, location, and morphological characteristics, which may improve lesion assessment and management. A review of the condition and reported complications is discussed.

Cardiac magnetic resonance findings in isolated congenital left ventricular diverticuli

Congenital ventricular diverticulum is a rare cardiac abnormality, frequently associated with other cardiac or non-cardiac congenital malformations. Clinically, congenital ventricular diverticulum may be asymptomatic or cause systemic embolization, heart failure, ventricular rupture, ventricular arrhythmia and sudden death. Cardiac magnetic resonance (CMR) can be a useful non-invasive and non-ionizing method to confirm the presence, size and extent of left ventricular (LV) diverticulum and its tissue characterization. In these reports we documented the presence of six diverticuli in patients underwent to CMR for other clinical indications. In all the cases, magnetic resonance showed an accurate assessment of diverticuli.

Congenital left ventricular aneurysms and diverticula: definition, pathophysiology, clinical relevance and treatment

A congenital left ventricular aneurysm or diverticulum is a rare cardiac malformation; 411 cases have been reported since its first description in 1816, and other cardiac, vascular or thoraco-abdominal abnormalities have been shown in about 70%. It appears to be a developmental anomaly, starting in the 4th embryonic week. Diagnosis can be made after exclusion of coronary artery disease, local or systemic inflammation or traumatic causes as well as cardiomyopathies. Clinically, most congenital left ventricular aneurysms and diverticula are asymptomatic or may cause systemic embolization, heart failure, valvular regurgitation, ventricular wall rupture, ventricular tachycardia or sudden cardiac death. Diagnosis is established by imaging studies such as echocardiography, magnetic resonance imaging or left ventricular angiography, visualizing the structural changes and accompanying abnormalities. Mode of treatment has to be individually tailored and depends on clinical presentation, accompanying abnormalities and possible complications; treatment options include surgical resection especially in symptomatic patients, anticoagulation after systemic embolization, radiofrequency ablation or implantation of an implantable cardioverter defibrillator in case of symptomatic ventricular tachycardia, occasionally combined with class I or III antiarrhythmic drugs.

A Contractile Left Ventricular Diverticulum

We present the first case report of left ventricle muscular diverticulum which stands in front of the right ventricle in an asymptomatic 20-year-old male. The diverticulum has a connection with the left ventricular outflow truct, and contracts simultaneously with the left ventricle. The patient has been included in our congenital anomaly follow-up program.

Occurrence of omphalocele in relation to maternal multivitamin use: a population-based study

OBJECTIVE

We evaluated the association between mothers' use of multivitamin supplements and their infants' risk for omphalocele, a congenital anomaly of the abdominal wall. Omphalocele can occur in certain multiple congenital anomaly patterns with neural tube defects, for which a protective effect of multivitamins with folic acid has been demonstrated.

METHODS

We used data from a population-based case-control study of infants born from 1968-1980 to mothers residing in metropolitan Atlanta. Case-infants with nonsyndromic omphalocele (n = 72) were actively ascertained from multiple sources. Control-infants (n = 3029), without birth defects, were selected from birth certificates by stratified random sampling.

RESULTS

Compared with no use in the periconceptional period, periconceptional use of multivitamin supplements (regular use from 3 months before pregnancy through the first trimester of pregnancy) was associated with an odds ratio for nonsyndromic omphalocele of 0.4 (95% confidence interval [CI]: 0.2-1.0). For the subset comprising omphalocele alone or with selected midline defects (neural tube defects, hypospadias, and bladder/cloacal exstrophy), the odds ratio was 0.3 (95% CI: 0.1-0.9). These estimates were similar when the reference group also included women who began using multivitamins late in pregnancy (during the second or third month of pregnancy). The small number of participants limited the precision of subgroup analyses and translated into wide confidence intervals that included unity.

CONCLUSIONS

Periconceptional multivitamin use was associated with a 60% reduction in the risk for nonsyndromic omphalocele. These findings await replication from additional studies to confirm the findings, generate more precise estimates, and detail possible mechanisms of actions.

Contrast harmonic power Doppler imaging of congenital ventricular diverticulum--a case report

A case of an 81-year-old woman with a left ventricular diverticulum who underwent myocardial contrast echocardiography is reported. After administration of the contrast agent, a pulsed Doppler flow measurement clearly revealed the biphasic waveform of the ejection flow in the pre-systolic and systolic phase at the ostium of the diverticular cavity. A harmonic power Doppler image showed that part of the diverticulum wall had similar acoustic properties to the ventricular septal wall. Intracardiac blood flow and myocardial perfusion could be clearly evaluated and a ventricular diverticulum was correctly diagnosed using contrast echocardiography.