Isolated congenital left ventricular diverticulum presenting as stable angina pectoris and surgical treatment

A congenital left ventricular diverticulum (LVD) is a relatively rare cardiac anomaly and has to be differentiated from an aneurysm or pseudoaneurysm. A recent large single-center study demonstrated that the prevalence of the left ventricular diverticulum in adults is 0.42% and one third of the affected patients had nonfatal cardiovascular events during follow-up [1]. Major concerns are thrombosis, embolism, rupture, congestive heart failure, ventricular arrhythmias and sudden cardiac death. In adults, LVD can be misdiagnosed as other types of heart diseases, especially when the present symptom is angina pectoris. In this report, we describe a congenital LVD on the apical wall presenting stable angina pectoris in an adult patient. The patient did not respond to conservative treatment and underwent successful surgical treatment.
A 43-year-old man was referred to our clinic because of complaints of angina-like chest pain, mainly on heavy exertion. The patient described the pain as tightness located in the retrosternal area with no radiation. The chest pain typically lasted 3 to 5 minutes and ordinary physical activity did not cause angina. His only risk factor was excess weight. The patient had no significant previous medical history.
On physical examination, no abnormal findings were obtained. The electrocardiogram showed T wave flattening/inversion on inferior leads. It was not suggestive of ischemia. The results of laboratory tests were unremarkable and also cardiac biomarkers were negative. A chest X-ray showed no abnormality and there was no clue about the source of the chest pain.
Two-dimensional transthoracic echocardiography (TTE), from the modified apical four-chamber view demonstrated “bird beak”-like outpouching on the apex of the left ventricle. During systole the volume of the outpouching was decreasing. The TTE ruled out associated congenital anomalies (Fig. 1).
We interpreted that the outpouching was probably an aneurysm, as a result of coronary artery disease. The patient underwent conventional coronary angiography which demonstrated mild coronary artery disease. A subsequent left ventriculography, obtained in 30° right anterior oblique projection, showed “bird beak”-like outpouching on the apical wall (Fig. 2).
Contrast-enhanced cardiac magnetic resonance imaging (MRI) with its advanced sequences characterized this outpouching very well and helped us to understand it was a congenital LVD (Fig. 3).
The...


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