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Heart Online First, published on October 27, 2017 as 10.1136/heartjnl-2017-312068
Image challenge
An abnormal structure of the
left ventricle
Clinical Introduction
A 36-year-old man was referred for evaluation of an abnormal
left ventricular (LV) structure found incidentally on transthoracic echocardiography (TTE) (figure 1). He had no symptoms
except for mild palpitations. There was no significant medical
history. Physical examination was unremarkable. ECG showed
regular sinus rhythm with ST changes in lead II, III, avF and V6
(see online supplementary file 1). Cardiac magnetic resonance
(CMR) (figure 1C) was performed. Treadmill exercise test did
not demonstrate any electrocardiographic ischaemic changes.
No arrhythmias were noted on Holter monitor. Which of the
following is most likely the diagnosis?
A: Lateral and inferolateral myocardial infarction
B: Congenital absence of pericardium
C: Pseudoaneurysm
D: Congenital left ventricular outpouching
Figure 1 Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR). (A) Parasternal left ventricular longitudinal axis view of TTE;
(B) colour Doppler of parasternal left ventricular longitudinal axis view of TTE; (C) left ventricular longitudinal axis view of CMR.
Kang Y, et al. Heart Month 2017 Vol 0 No 0
Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd (& BCS) under licence.
Downloaded from on October 28, 2017 - Published by
Image challenge
Figure 2 Transthoracic echocardiography indicated several narrow necks connecting LV and LVO ((B) Arrow). AO, aorta; LA, left atrium; LV, left
ventricle; LVO, left ventricular outpouching; RV, right ventricle.
Answer: D
TTE demonstrated a protrusion at the lateral and inferolateral
basal wall synchronously contracting with the LV. There are
several narrow connection necks between the protrusion and LV
with blood entering from the LV into the protrusion during diastole and flowing out during systole (figure 2, see online supplementary video 2 and online supplementary video 3). No late
contrast enhancement was observed on CMR excluding fibrosis
or scar tissue (see online supplementary video 4).
Congenital left ventricular outpouching (LVO) is a rare anomaly.
Several terms have been used in the literature including LV aneurysm, LV diverticulum, LV accessory chamber and double-chambered LV.1 Malakan et al2 introduced a classification for congenital
LVOs based on LV geometry, small outpouching size, and normal
thickness and wall motion, all of which have been associated with
better outcomes. Congenital non-apical LVO is more commonly
found as an isolated anomaly while apical LVO is commonly associated with intracardiac or extracardiac malformation.3 Haegeli
et al4 have reported that 13% of patients with LVO presented
with arrhythmic manifestations. Sustained ventricular tachycardia corresponding to the anatomic location of LVO was the
most documented arrhythmia. There were no arrhythmias in the
present case and only periodic follow-up was recommended.
The history, ECG and normal wall motion demonstrated by
TTE and CMR makes myocardial infarction and LV pseudoaneurysm incorrect choices. Partial absence of pericardium may
cause left atrium, LV herniation, aneurysm or regional bulging,5
which could be diagnosed by CMR. In this case, the presence of
myocardium and pericardium of the protrusion exclude pseudoaneurysm and congenital absence of pericardium.
This work was supported by grant no. 81401411 from
the National Nature Science Foundation of China, grant no.
14ZR1425200 and grant no. 16ZR1420600 from Nature
Science Foundation of Shanghai.
Yu Kang, Zheng Li, Ben He
Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong
University, Shanghai, China
Correspondence to Dr Ben He, Department of Cardiology, Renji Hospital, School
of Medicine, Shanghai Jiaotong University, 1630 Dongfang Rd, Shanghai, China; ​
[email protected]​163.​com
Acknowledgements The authors thank Zhikai Zhan and Jiahe Tian for their efforts
on word-processing.
Funding This work was supported by grants No. 81401411 from the National
Nature Science Foundation of China and No. 14ZR1425200 and No. 16ZR1420600
from Nature Science Foundation of Shanghai.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Renji Hospital Research Ethics Committee.
Provenance and peer review Not commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
►► Additional material is published online only. To view please visit the journal
online (http://​dx.​doi.​org/​10.​1136/​heartjnl-​2017-​312068).
YK and ZL contributed equally.
To cite Kang Y, Li Z, He B. Heart Published Online First: [please include Day Month
Year]. doi:10.1136/heartjnl-2017-312068
Received 27 June 2017
Revised 23 August 2017
Accepted 12 September 2017
Heart 2017;0:1–2. doi:10.1136/heartjnl-2017-312068
1 Hubacek J, Brydie A, Jackson S. Multiple congenital left ventricular diverticula and
aneurysm. J Am Coll Cardiol 2009;53:1087.
2 Malakan Rad E, Awad S, Hijazi ZM. Congenital left ventricular outpouchings: a
systematic review of 839 cases and introduction of a novel classification after two
centuries. Congenit Heart Dis 2014;9:498–511.
3 Dipak NK, Venkatesh S, Prabhu S, et al. Evolution of ventricular outpouching through
the fetal and postnatal periods: Unabating dilemma of serial observation or surgical
correction. J Saudi Heart Assoc 2017;29:203–10.
4 Haegeli LM, Ercin E, Wolber T, et al. Arrhythmic manifestations in patients with
congenital left ventricular aneurysms and diverticula. Am J Cardiol
5 Shah AB, Kronzon I. Congenital defects of the pericardium: a review. Eur Heart J
Cardiovasc Imaging 2015;16:821–7.
Kang Y, et al. Heart Month 2017 Vol 0 No 0
Downloaded from on October 28, 2017 - Published by
An abnormal structure of the left ventricle
Yu Kang, Zheng Li and Ben He
Heart published online October 27, 2017
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