P1492 A rare case of a spontaneous rupture of a congenital inter ventricular septum diverticulum in an adult

Abstract

Introduction A ventricular diverticulum is a rare cardiac anomaly with its true incidence is likely to be underestimated, as most patients are thought to be asymptomatic. Possible known complications include conduction abnormalities, rupture, bacterial endocarditis, and thromboembolism. We report a case of inter ventricular septum diverticulum detected incidentally in an adult during echocardiography and which ruptured spontaneously after 3 years of follow up. Case report A 36-year-old asymptomatic gentleman was referred for cardiac evaluation as a part of pre employment general check-up. He was controlled hypertensive on medical treatment. He had no history myocardial infarction (MI), arrhythmias, or stroke. He had never experienced exertional dyspnoea or chest pain. Physical examination was unremarkable. Transthoracic echocardiography revealed mild left ventricle hypertrophy with normal global and regional contractility with an ejection fraction of 58%. In addition, it showed a myocardial out-pouching (11x9 mm) localized at the basal third of the posterior inter-ventricular septum and bulging into the right ventricle and moving in synchrony with the rest of the left ventricle with no shunt (figures A&B&C). The patient’s history allowed us to exclude a post-ischemic LV aneurysm and an infective genesis of the lesion. Contrast enhanced EKG gated cardiac computed tomography confirmed the presence of a blind ended diverticulum of the interventricular septum which was stretching and protruding into the right ventricle. The septum and the diverticulum were intact with no evidence of associated septal defects, (figures D&E&F). Three years later, during his regular follow up, a loud pan-systolic murmur was heard along the left sternal border. His repeated echocardiographic study revealed a rupture of the inter ventricular septal diverticulum into the right ventricle, with a left to right shunt of a peak systolic gradient of 71 mmHg, (Fig G). His blood pressure was 100/60. Cardiac magnetic resonance confirmed the rupture of the interventricular septum diverticulum. It revealed a tiny defect with a left to right shunt and the calculated QP/QS was 1.3, (fig H&I). As the patient was asymptomatic and the shunt was insignificant, the decision was made to be managed conservatively and not to intervene with surgery at this point. This was to avoid the potential of surgical complications as disruption of the patient’s conduction system and the chance of post-operative arrhythmia. Abstract P1492 Figure.