A Large Left Ventricular Diverticulum in a Patient With Congenital Pulmonic Stenosis

Abstract

A 56-year-old asymptomatic white woman underwent transthoracic echocardiography. She had a history of moderate to severe congenital pulmonic stenosis for which she underwent surgical valvotomy at age 14 years. The echocardiogram showed a normal transpulmonic pressure gradient. From the apical 4-chamber view of the contrast-enhanced echocardiogram, the left ventricle had a “bifurcating” or “mirror image” appearance with a large outpouching laterally (Fig. 1A, arrows). This outpouching structure had a wide neck, normal contractility, and near-complete emptying (Fig. 1B, end systole). Cardiac magnetic resonance imaging (MRI) was performed to further characterize this unusual structure. The cardiac MRI axial 4-chamber view demonstrated a large (4.7 cm) anterolateral left ventricular (LV) diverticulum with normal contractility (Fig. 1C, end-diastole; Fig. 1D, endsystole; Video 1 , view video online). The cardiac MRI short-axis view from the base to the apex revealed prominent trabeculation (Fig. 1, E-G; Video 2 , view video online). No mural thrombus was seen. The LV ejection fraction was 56%. Delayed enhanced images showed no scar. Before her previous pulmonic valve surgery, left ventriculography was performed in the anterior-posterior view, which could have missed this laterally located diverticulum. Congenital LV diverticulum is a rare malformation. LV diverticulum with concomitant congenital pulmonic stenosis is extremely rare. LV diverticula should be differentiated from LV aneurysms or pseudoaneurysms in patients with history of cardiac surgery or adults at risk for atherosclerotic