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CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehs051
Online publish-ahead-of-print 16 April 2012
An unusual cause of systolic murmur
Pablo Ávila*, Esther Pérez-David, and Francisco Fernández-Avilés
Cardiology Department, Hospital General Universitario Gregorio Marañón, Dr Esquerdo 46, 28007 Madrid, Spain
* Corresponding author. Tel: +34 915868290, Fax: +34 915868278, Email:
An asymptomatic 46-year-old man
was referred to our institution for
evaluation of a cardiac murmur
discovered in a routine medical
checkup. Physical examination
showed a harsh systolic murmur
IV/VI in the left parasternal edge.
An electrocardiogram showed
negative T-waves in left precordial
leads. Transthoracic echocardiogram was normal, except for an
apical protrusion of 3 × 4 cm
(Panel A; see Supplementary material online, Video S1), which
appeared to have its own endocardium, myocardium, and pericardium. Acceleration through its
narrow neck with a peak gradient
of 95 mmHg (Panel B; see Supplementary material online, Video S2)
was revealed by colour and continuous Doppler. These findings
were confirmed by contrast echo
(Panel C; see Supplementary material online, Video S3) and
cardiac magnetic resonance cine images (Panels D and E; see Supplementary material online, Video S4A and B). Delayed-enhancement
imaging showed intramyocardial fibrosis in the diverticulum (Panels F and G).
These findings were compatible with an isolated muscular left ventricular apical diverticulum. The patient preferred conservative
management, and serial follow-up was decided.
Congenital ventricular diverticulum is a rare congenital cardiac defect, which can be muscular or fibrous. The fibrous type is a noncontractile ventricular protrusion. The muscular type is usually located in the apex and may show active contraction as it contains the
three cardiac layers. Most of the cases are associated with midline thoracoabdominal defects and other heart malformations and are
therefore detected in children. In contrast, patients with an isolated left ventricular diverticulum generally remain asymptomatic.
However, due to potential risk of life-threatening complications such as cardiac rupture or ventricular tachycardia, correct attitude
in asymptomatic patients remains controversial.
Supplementary material is available at European Heart Journal online.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email:
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