Multimodality Imaging and Clinical Significance of Congenital Ventricular Outpouchings: Recesses, Diverticula, Aneurysms, Clefts, and Crypts

Abstract

The high spatial resolution of cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) permit the diagnosis of congenital ventricular outpouchings (CVOs), including congenital ventricular diverticula (CVD), congenital ventricular aneurysms (CVA), clefts, and crypts. A unique classification has not been established, and these terms are used interchangeably with confounding terminology. Moreover, their significance is not univocal. A research was performed using PubMed on six subjects: (1) congenital left ventricular outpouchings; (2) congenital ventricular diverticulum; (3) congenital ventricular aneurysm; (4) ventricular clefts; (5) ventricular crypts; and (6) ventricular crevices. Usually, CVOs are small with a preserved contraction and in asymptomatic patients, the clinical relevance may be minimal, although electrocardiographic anomalies are often present. CVA and diverticula may carry an embolic risk and cases of arrhythmia and rupture are described. In the presence of clefts, or crypts a cardiomyopathy should be excluded. A simple classification can be proposed: CVD extend beyond the myocardial wall and fibrous type may be termed CVA, acquired forms should be kept distinct. Clefts, or crypts, are small recesses extending for more than 50% of the ventricular wall but not beyond its margin. The presence of fibrosis may be evaluated by CMR. A multicenter prospective registry would be helpful to investigate potential clinical implications and to exclude dubious forms of hypertrophic cardiomyopathy or ventricular noncompaction. In conclusion, CVOs have been described with different terminologies and classifications. Their significance needs to be interpreted in the clinical setting and with the help of a multimodality imaging, particularly of CMR.

Phenotypes of hypertrophic cardiomyopathy. An illustrative review of MRI findings

“…Congenital LV diverticula are characterised by an outpouching that contains endocardium, myocardium, and pericardium, and they are a narrow connection to the cavity and collapse at end-systole. The primary diagnostic feature to differentiate diverticula from crypts is that the congenital diverticula extend outside the epicardial border while crypts remain confined inside the myocardial margin [ 23 ].…”

Cardiac magnetic resonance imaging in the evaluation of patients with hypertrophic cardiomyopathy

“…Cine SSFP can also demonstrate the presence of a turbulence jet across the left ventricular outflow tract (LVOT) in patients with obstructive HCM, and aid in the exact location of the flow obstruction site. Moreover, SSFP CMR can detect other abnormalities associated with HCM such as the presence of congenital ventricular outpouchings (recesses, diverticula, aneurysms, clefts, and crypts) 20 , anomalies in the mitral valve apparatus and abnormalities of the papillary muscles 21 . Late gadolinium enhancement (LGE) imaging provides non-invasive tissue characterization by identification of HCM associated interstitial and replacement fibrosis 22 .…”

A Large Congenital Ventricular Outpouching

“…The Journal of Tehran University Heart Center 43 J Teh Univ Heart Ctr 14 (1) http://jthc.tums.ac.ir January, 2019 Coronary artery angiography showed normal coronary arteries, and ventriculography revealed a narrow-necked outpouching in the posterobasal LV wall with systolic contractions, suggestive of an asymptomatic huge ventricular diverticulum ( Figure 3). The patient refused to undergo cardiac magnetic resonance imaging despite our recommendation.…”

“…Congenital LV diverticula constitute a rare congenital disorder, especially in adulthood. 1 Although most of these diverticula are congenital in etiology, one can never be sure. Diverticula are more prevalent in Asia than are primary LV aneurysms and are associated with other cardiac and extracardiac anomalies in more than 30% of cases.…”

“…The most common differential diagnosis is a ventricular aneurysm, which can be differentiated according to the morphology of the defect and the associated coronary artery disease in secondary type aneurysms. 1,2 Arrhythmias, emboli and strokes, ruptures, and even sudden cardiac deaths are the rare complications of diverticula. The management is done individually according to the patient's symptoms and associated complications; however, there is not a documented outcome and a valuable long-term follow-up.…”