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Incidentally diagnosed congenital left ventricular aneurysm: report of two cases/Tesadufen tani konulmus konjenital sol ventrikuler anevrizma: iki olgu sunusu.

Introduction

Congenital ventricular diverticulum and aneurysm are two distinct rare entities with different morphologic and histological characteristics and outcomes. Congenital ventricular diverticulum and aneurysm have a reported prevalence ranging from 0.4% to 0.8% (1, 2). Although congenital diverticulum is usually associated with other anomalies such as Cantrell pentalogy, a congenital aneurysm is frequently detected as standalone finding (3). The differential diagnosis of these two conditions is cumbersome for the clinician. Nevertheless, a wide neck, the absence of normal ventricular layers and paradoxical contraction point to the presence of an aneurysm (4).

We report here incidentally diagnosed two congenital left ventricular aneurysm cases in which different imaging modalities were used.

Case 1

A 24-year-old male was admitted to our clinic with a complaint of atypical chest pain. His physical examination was unremarkable except apical mild late-systolic murmur. Electrocardiography and routine blood chemistry were also within normal limits. Transthoracic echocardiographic examination revealed a mild mitral regurgitation and an outpouching located at posterior wall on parasternal long axis view (Video 1. See corresponding video/movie images at www.anakarder.com). This akinetic structure was also observed at the inferior wall (Video 2. See corresponding video/movie images at www.anakarder.com).

We thought that the patient had coronary artery disease and hence coronary angiography was performed. However, it revealed a normal coronary artery anatomy and a non-contractile structure suggesting an aneurysm approaching 1.5 cm diameter (Fig. 1). We performed a cardiac scintigraphy for better delineation of the problem, which confirmed an inferiorly-located outpouching without any evidence of ischemia (Fig. 2). Based on these findings we decided that the patient has a congenital left ventricular aneurysm located at basal ventricular region and should be followed with regular sixth month intervals.

Case 2

A 21-year-old male patient was studied for exertional dyspnea. His physical examination was unremarkable except leftward displacement of the apical pulse. His electrocardiography and routine blood chemistry were within normal limits. The chest X ray showed an enlarged cardiac silhouette. His transthoracic echocardiographic examination revealed slightly enlarged left ventricular cavity with apically localized wide akinetic area (Video 3. See corresponding video/movie images at www.anakarder.com). Left ventricular ejection fraction calculated by modified Simpson rule was within normal limits (53%).Coronary angiography was normal except left confirmed the presence of apically localized thin-walled aneurysm (Fig. 3). We accepted it as having a congenital anomaly. We advised the patient surgical correction of the problem for preventing aneurysm-related future complications but he refused surgical option. We prescribed warfarin with a targeted INR 2-3.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Discussion

Marijon et al. (5) recently reported that congenital left ventricular diverticulum and aneurysm are two distinct entities with worse outcome in the latter. Therefore, the correct diagnosis may influence the treatment options. However, this task is not so easily performed event in current era. Among the parameters much frequently used for differential diagnosis neck size (wide or narrow) and synchronous contractility (4) seem to have practical importance because histological confirmation of all ventricular layers is not always possible in every case.

In our cases, we confronted with incidentally diagnosed structures necessitating a differential diagnostic work-up. In the first case posterobasally located akinetic area showed relatively wide neck and paradoxical movement with ventricular systole. Aneurysmatic area in the second case, albeit larger, had also wide neck but its contractility was interpreted as akinetic. The absence of other cardiac orthoracoabdominal midline deformities, in our opinion, supported the aneurysm diagnosis (5).

Congenital left ventricular aneurysms are frequently encountered in the apex and free wall (3). However, basal location is also possible (6) as in our first case. Arrhythmia, heart failure, thromboembolism and rupture may cause significant morbidity and sometimes, mortality in these patients (3). In asymptomatic patients, the therapy specifically addressing thromboembolic complications is recommended (3). Therefore, we decided to follow our first case because he had none of the risk factors and his aneurysm was relatively small. We interpreted the second case's symptoms as related to underlying pathology so surgical therapy was recommended.

Conclusion

Advanced imaging modalities including two or three dimensional echocardiography, computed tomography and magnetic resonance imaging may increase accidentally diagnosed left ventricular outpouchings. Moreover, these diagnostic techniques may also be used for follow-up of the patients and may provide valuable information about the natural history of congenital aneurysms.

[FIGURE 3 OMITTED]

References

1. Sakabe K, Fukuda N, Fukuda Y, Wakayama K, Nada T, Morishita S, et al. Isolated congenital left ventricular diverticulum in an elderly patient that was identified because of an incidental finding during a complete medical checkup. Int J Cardiol 2008; 125: e30-3

2. Perez-Fernandez R, Medina-Alba R, Mantilla R, Soler R, Pradas G, Penas-Lado M. Congenital apical left ventricular aneurysm. Rev Esp Cardiol.2005; 58: 1361-3.

3. Papagiannis J, Van Praagh R, Schwint O, D'Orsogna L, Qureshi F, Reynolds J, et al. Congenital left ventricular aneurysm: clinical, imaging, pathologic, and surgical findings in seven new cases. Am Heart J. 2001; 141: 491-9.

4. Tissot C, Pache JC, da Cruz E. Clinical vignette. A giant congenital left ventricular diverticulum simulating an aneurysm. Eur Heart J. 2007; 28: 25.

5. Marijon E, Ou P, Fermont L, Concordat S, Le Bidois J, Sidi D, et al. Diagnosis and outcome in congenital ventricular diverticulum and aneurysm. J Thorac Cardiovasc Surg 2006;131:433-7.

6. Franco-Vazquez S, Sutherland RD, Fowler M, Edwards JE. Congenital aneurysm of the left ventricular base. Chest 1970; 57: 411-5.

Oben Baysan, Mehmet Uzun, Mehmet Yokusoglu, Cem Koz, Guvenc Inanc*, Ozdes Emer**

From Departments of Cardiology, *Radiology and **Nuclear Medicine, Gulhane Military Medical School, Ankara, Turkey

Address for Correspondence/Yazisma Adresi: Dr. Mehmet Yokusoglu, Gulhane Military Medical School, Department of Cardiology, Ankara, Turkey Phone: +90 312 304 42 67 Fax: +90 312 304 42 50 E-mail: myokusoglu@yahoo.com
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Article Details
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Baysan, Oben; Uzun, Mehmet; Yokusoglu, Mehmet; Koz, Cem; Inanc, Guvenc; Emer, Ozdes
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Case study
Geographic Code:7TURK
Date:Jun 1, 2008
Words:962
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