Introduction
Congenital left ventricular (LV) diverticulum is a rare cardiac anomaly which can be complicated with infective endocarditis, embolisms, arrhythmia and, rarely, rupture1-4 . If ruptured, the outcome is usually poor with high mortality. We report a case of LV pseudo-aneurysm with ruptured diverticulum and successful surgical repaired.
A 41-year-old woman presented with a history of chest tightness and shortness of breath for 6 months. On clinical examination, blood pressure was 124/86 mmHg. The ECG showed sinus rhythm without evidence for ischemic changes, and chest X-ray revealed an enlarged heart. A transthoracic echocardiography (TTE) showed 20 mm discontinuity (with narrow connection neck) of basal segment of the inferior wall with 88 mm × 71 mm echo-free space, suggesting pseudo-aneurysm formation wrapped within the pericardial (Fig 1A). There was a marked thrombus in the pseudo-aneurysm with large pericardial effusion (Fig 1B). Color Doppler demonstrated blood flow across the narrow neck of the pseudo-aneurysm (Fig 1C). Overall LV systolic function was preserved with no other combined abnormality.
The patient did not have any history of myocardial infarction, prolonged fever, chest trauma or any cardiac surgery. Coronary angiogram confirmed normal coronary arteries (Fig 2A & 2B), and cardiac magnetic resonance imaging (MRI) confirmed the presence of the LV pseudo-aneurysm, on late gadolinium enhancement (LGE) showing LV pseudo-aneurysm with thin wall corresponding to fibrosis and/or scar (Fig 3A & 3B).
The patient underwent surgery, during which a large pseudo-aneurysm of LV inferior wall was confirmed with a thrombus inside. The pseudo-aneurysm was closely adherent to the pericardium of the diaphragmatic surface (Fig 4). Surgical repair with a pericardial patch was performed, and postoperative TTE showed normal LV function with the patch located at the inferior wall. Pathological investigations showed the aneurysm size was 70 × 60 × 35 mm. Based on the imaging, pathological results and medical history we considered that the ventricular aneurysm was a congenital LV diverticulum, which ruptured and caused a ventricular pseudo-aneurysm.