Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Abstract

Background and Aims. Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making. Methods. The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated. Results. Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes. Conclusions. Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

Isolated muscular ventricular diverticulum assessment using multi‐parameter echocardiographic imaging: Case reports

“…Intrauterine viral infections, muscular or connective tissue defects, and excessive primordial cell stimulation have been suggested as possible favorable conditions for disruption of embryogenesis. 8 The clinical presentation of VDi varies widely, from asymptomatic adult patients to prenatal rupture cases, with syncope and arrhythmia being the most common symptoms. Based on the classification as either muscular or fibrous type, muscular diverticula contain all three layers of cardiac tissue and systolic contraction synchronous, otherwise it is fibrous type and prone to rupture.…”

“…3,8,10 and the diagnosis should consider the patient's medical history, clinical manifestations and imaging findings, although each may exhibit unique morphological, functional and hemodynamic features. Differential diagnoses and classification were determined based on medical imaging, including key points of morphology, outpouching wall and chamber and kinetic, as shown in Table1.…”

Dilated left ventricle with multiple outpouchings — a severe congenital ventricular diverticulum or left-dominant arrhythmogenic cardiomyopathy: A case report

“…Third, CVD patients exhibit more frequent extracardiac anomalies than those with LDAC[ 19 ]. Fourth, the size of CVD does not change over time, suggesting a benign course[ 23 ]. However, the patient in the present study not only manifested multiple left ventricular outpouchings but also exhibited uneven-thickness left ventricular wall with multiple flaky fatty infiltrations.…”

Cross-sectional imaging findings of cardiac outpouchings

“…Both are usually located in the anterior upper wall of the LA and can be associated with thromboembolism, stroke, and arrhythmia. 1,2,13 The presence of these outpouchings should be examined before invasive procedures (such as radiofrequency ablation) to prevent complications, such as wall penetration and atrioesophageal fistula. 1,3 Diverticulum, aneurysm, and pseudoaneurysm of the right atrium (RA) Diverticula, aneurysms, and pseudoaneurysms of the RA are unusual outpouchings and may present similar clinical and radiological findings.…”

“…1,2,13 The presence of these outpouchings should be examined before invasive procedures (such as radiofrequency ablation) to prevent complications, such as wall penetration and atrioesophageal fistula. 1,3 Diverticulum, aneurysm, and pseudoaneurysm of the right atrium (RA) Diverticula, aneurysms, and pseudoaneurysms of the RA are unusual outpouchings and may present similar clinical and radiological findings. These are characterized by outpouchings that originate from the RA appendage (Figure 14).…”