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\begin{document}

\title{Congenital Left Ventricular Diverticulum Repair in an Adult with Dual
Patch Technique}



\author[1]{Javier Mejia}%
\author[2]{Stephen Spindel}%
\author[3]{Amit Pawale}%
\author[3]{Shinobu Itagaki}%
\author[2]{Percy Boateng}%
\affil[1]{Mount Sinai Hospital}%
\affil[2]{The Mount Sinai Hospital}%
\affil[3]{Mount Sinai Medical Center}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\begin{abstract}
Rupture of a congenital left ventricular diverticulum (CLVD), a rare
anatomical anomaly, is a catastrophic event, with potential fatal
consequences. Repair techniques documented in the literature include
primary closure and single patch closure. We describe a case of a
57-year-old woman with symptomatic anterolateral CLVD. Our approach
involves a linear incision through the epicardial surface of the
diverticulum with exclusion of the cavity, and restoration of normal
ventricular geometry via a two patch technique.%
\end{abstract}%



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\textbf{Introduction}

Congenital left ventricular diverticulum (CLVD) consists of an
outpouching of endocardium, myocardium, and pericardium, which often
presents as a projection from the ventricular free wall, with a narrow
neck connecting the cavity to the ventricle proper {[}1{]}. Due to its
composition of normal cardiac tissue, as compared to a congenital left
ventricular aneurysm (CLVA), the diverticulum contracts synchronously
with the remainder of the ventricle. Thromboembolic events, ventricular
arrhythmias, heart failure, and free wall rupture have been documented
to occur. Due to its low overall prevalence between 0.02\% to 0.76\%
{[}2, 3, 4{]}, and variability in presentation, a standardized treatment
paradigm has yet to be delineated. We report the successful repair of a
congenital left ventricular diverticulum using a two patch technique.

\textbf{Technique}

A healthy 57-year-old female was evaluated for frequent episodes of
atypical chest pain, which revealed a CLVD. She had no history of
myocardial infarctions, mediastinal infections, or trauma. A computed
tomography angiography demonstrated an anterolateral left ventricular
outpouching measuring 4.9 x 3.8 x 1.6 cm, accompanied by a narrow neck
with areas of thick and thin wall containing trabeculations. A cardiac
magnetic resonance imaging study confirmed similar dimensions and noted
the walls to be thinned in focal regions (Fig 2). Coronary angiogram
showed normal coronary arteries.

Intraoperative transesophageal echocardiogram showed blood flow into the
CLVD. Through a median sternotomy, the patient was placed on
cardiopulmonary bypass with ascending aortic arterial and right atrial
venous cannulation. The heart was arrested and the left ventricle
inspected. A 5 x 4 cm area of protrusion with thinned myocardium was
noted on the anterolateral aspect of the left ventricle (Fig 1A). The
thinned area of tissue was opened through a 5 cm linear incision (Fig
1B). The discrete neck communicating with the left ventricular wall
measured 3 cm, allowing flow between the CLVD and the left ventricle.
Multiple pledgeted 4-0 polypropylene horizontal mattress sutures were
passed from outside-to-in through the rim of healthy appearing
myocardium just above and around the diverticular neck. These were then
each passed through the perimeter of a circular 6 x 4
cm\emph{Hemashield} (Maquet Holding, Rastatt, Germany) patch that laid
on top and flush with the diverticular neck, and subsequently tied (Fig
1C). Care was taken to inspect and avoid the subvalvular mitral
apparatus. The patch sealed off the CLVD from the left ventricular
cavity while avoiding compromising the true ventricular lumen (Fig 1D),
its geometry, or reducing the intraventricular volume.

A second set of pledgeted 4-0 polypropylene sutures were placed from
inside the CLVD in a horizontal mattress fashion, circumferentially
around the linear incision through the wall of the diverticulum. These
sutures were taken more proximal to the epicardial surface, above the
level of the first patch placed near the diverticular neck, encircling
the incision into the diverticulum (Fig 1E). The incision into the
cavity was then oversewn with two running 4-0 polypropylene sutures,
with a pledget on either side of the incision, ensuring appropriate
approximation, but with care to apply minimal tension to either free
edge, limiting how tightly they were brought together (Fig 1F).

A second circular \emph{Hemashield} patch 7 cm in diameter was then
fashioned. Half of the adjacent epicardial mattress sutures were then
passed through this patch. The patch was subsequently lowered and these
adjacent sutures were securely tied, leading to half the patch being
secured to the surface of the epicardium. \emph{BioGlue} (CryoLife Inc,
Georgia, United States) was applied to this pocket of space between the
epicardium and the \emph{Hemashield} patch, with the other half of the
remaining adjacent sutures then passed through the patch and tied
securely once the glue had been allowed to settle (Fig 1G).

The cross clamp was removed and the patient weaned off bypass.
Transesophageal echocardiogram showed good biventricular function
without a compromise in ventricular lumen, with no communication, and
complete exclusion of the diverticular cavity. Her post-operative course
was uneventful.

\textbf{Comment}

CLVD often represent novel territory with regards to management and, at
times, diagnosis for most heart teams. Not only is the prevalence fairly
low, ubiquitously lower than 1\% as previously described, but
additionally the natural history of the disease is not well delineated.
There are two distinct pathologies that are clearly described in the
literature, with CLVD representing an outpouching from the ventricle,
with synchronous contraction, and histologically similar to that of the
ventricular wall from which it protrudes. Congenital left ventricular
aneurysm (CLVA) represents the other end of the spectrum, whereby the
outpouching is dyskinetic or altogether akinetic, and histologically
composed of fibrous tissue, dissimilar to that of the ventricular wall
{[}5{]}. Despite the dearth of epidemiological data, CLVD are not
clinically silent, with reports of important cardiac complications such
as thromboembolism, ventricular arrhythmias, and myocardial ischemia.
Additionally, catastrophic CLVD rupture has been described, leading to
sudden death {[}6{]}.

Due to the rarity of CLVD, there is little guidance for the clinician
regarding appropriate treatment paradigms, be it a surgical or
conservative approach. In a review of 809 patients published since 1816
with either CLVD or CLVA, 4.5\% of patients with CLVD were found to have
an episode of rupture, and a 5.0\% reported rate of cardiac death. Other
significant complications included ventricular tachycardia/fibrillation
in 13.1\%, embolic events 3.6\%, and syncope 5.1\% {[}7{]}.

Despite the existence of a concise review of the cases reported to date,
there is little in the way of a detailed surgical approach. Some authors
have reported closure of the diverticulum neck with a patch, with
surgical glue closure and plication with aneurysmorrhaphy {[}8{]}. Other
authors have described their technique as suture reapproximation in a
double layered fashion with the use of felt {[}9{]}, while some describe
removal of the outpouching cavity and closure with an in-situ patch
{[}10{]}.

Due to the catastrophic events associated with CLVD, our institution
prefers surgical management for patients with symptomatic CLVD. The
first patch of our two patch technique helps retain the native geometry
of the left ventricle. Meanwhile, linear closure of the CLVD may cause a
reduction of the ventricular diameter and distortion of contractile
force vectors. The addition of a second patch to the ventricular
epicardial surface in our approach decreases early postoperative
bleeding and should minimize long term aneurysm formation and rupture.
Further study is necessary to determine the benefits of this technique.

\textbf{Disclosure}

This manuscript has not been published elsewhere. No conflicts of
interest for any of the authors.

\textbf{References}

1. Ohlow M, -A, Congenital Left Ventricular Aneurysms and Diverticula:
Definition, Pathophysiology, Clinical Relevance and Treatment.
Cardiology 2006;106:63-72

2. Albrecht G: Morphology and formal etiology of congenital heart
diverticula. Zentralbl Allg Pathol 1972;116:42--47.

3. (Cardiology Images 12)Ohlow M.-A., Secknus M. A., Geller J. C., von
Korn H., Lauer B. Prevalence and outcome of congenital left ventricular
aneurysms and diverticula in an adult population. Cardiology.
2009;112(4):287--293. doi: 10.1159/000159122.

4. (Cardiology Images 18) Albrecht G. Beirtrag zur Morphologie und
formalin Genese kongeintaler Divertkil. Zentralbl Allg Pathol.
1972;116(1):42--47.

5. Halpern L, Garabedian C, Worrall NK. Congenital Ventricular
Diverticulum or Aneurysm: A Difficult Diagnosis to Make. Case Rep
Cardiol. 2018;2018:5839432. Published 2018 Nov 11.
doi:10.1155/2018/5839432

6. S. Yalonetsky, Y. Agmon, J. Lessick. Contrast echocardiographic
imaging of left ventricular diverticulum in adult patients. J Am Soc
Echocardiogr, 20 (2006), pp. e1-e3

7. Ohlow MA, von Korn H, Lauer B. Characteristics and outcome of
congenital left ventricular aneurysm and diverticulum: Analysis of 809
cases published since 1816. International Journal of Cardiology. 2015
Apr;185:34-45. DOI: 10.1016/j.ijcard.2015.03.050.

8. Jung JC, Oh HC, Kim KH. Isolated Congenital Left Ventricular
Diverticulum in Adults. Korean J Thorac Cardiovasc Surg.
2015;48(5):355--358. doi:10.5090/kjtcs.2015.48.5.355

9. Scardigno AD, Chieppa DRR, Deluca G, Carbonara V. Isolated Congenital
Left Ventricular Diverticulum: A Case Report and Differential Diagnosis.
J Cardiovasc Echogr. 2016;26(1):19--21. doi:10.4103/2211-4122.178467

10. Manabu Yamasaki, Naoto Kawamatsu, Kunihiko Yoshino, Kohei Abe,
Hiroyasu Misumi, Congenital Left Ventricular Diverticulum Complicated by
Ventricular Fibrillation, The Annals of Thoracic Surgery, Volume 104,
Issue 3, 2017, Pages e271-e273, ISSN 0003-4975,
https://doi.org/10.1016/j.athoracsur.2017.03.029.\selectlanguage{english}
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