A 22-year-old male patient, admitted with atypical chest pain of sudden onset, had a holosystolic murmur at the apex, graded at 2 out of 6. His electrocardiogram was normal. Transthoracic echocardiography (Fig. 1), when analysed in apical four-chamber (a) and long axis (b) views, revealed an isolated diverticulum of the muscular ventricular septum (arrow). There was no obstruction of the right ventricular outflow, no shunting through the diverticulum, and only mild regurgitation across the mitral valve. More detailed evaluation by contrast enhanced computed tomography (Fig. 2 and video 1 – see www.journals.cambridge.org/CTY), when analysed in sagittal two-chamber (a), short-axial (b and d), and coronal four-chamber (c) views, confirmed the presence of a large muscular out-pouching (asterisk) of the ventricular septum close to the region of the membranous part of the septum. Careful interrogation of the images showed that the out-pouching had muscular walls, and hence was a diverticulum of the muscular ventricular septum, rather than an aneurysm of the membranous septum.
Figure 1
Figure 2
While refined noninvasive imaging has increased the specificity of diagnosis of left ventricular diverticulums,Reference Srichai, Hecht, Kim and Jacobs1 their classification, aetiology, and significance remain controversial. Myocardial noncompaction was excluded in our patient, since there was only a single ventricular recess. Intracardiac shunting might have favoured a diagnosis of septal aneurysm, but was not present in our patient. It is not possible to know whether this malformation represents the residua of a tunnel-like ventricular septal defect, which closed spontaneously. In the absence of obstruction of the right verntricular outflow tract, or a ventricular septal defect, surgical intervention was not recommended. The patient remains under careful observation.
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