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LETTER TO THE EDITOR
Double-chambered left ventricle in an adult: diagnosis by CMRI
Marcelo Souto NacifI,,II,
Corresponding author
msnacif@gmail.com

Tel.: www.msnacif.med.br
, Ricardo A F MelloIII, Orly O Lacerda JuniorIV, Christophe T SibleyI, Renato A MachadoV, Edson MarchioriVI
I National Institutes of Health - Radiology - Clinical Center, Bethesda, Maryland, United States.
II Johns Hopkins School of Medicine - Cardiology, Baltimore, Maryland, United States.
III Universidade Federal do Espírito, Vitória, Espirito Santo, Brazil.
IV UNIMED (CIAS) – Cardiology, Vitória, Espirito Santo, Brazil.
V UNIMED (CIAS) – Radiology, Vitória, Espirito Santo, Brazil.
VI Universidade Federal do Rio de Janeiro – Radiology, Rio de Janeiro, Rio de Janeiro, Brazil.
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging &#40;MRI&#41; with the cine &#40;A&#44; B&#44; D&#44; and E&#41; and late enhancement &#40;C and F&#41; techniques&#46; A&#44; Cine-MRI&#44; short-axis view at the apical portion of the left ventricle &#40;LV&#41; showing both cavities&#46; B&#44; Cine-MRI&#44; short axis view at the middle portion of LV showing both cavities&#46; C&#44; Delayed enhancement&#44; short-axis view at the middle portion of LV without scar&#47;fibrosis&#46; D&#44; Cine-MRI four-chamber view at diastole showing both cavities&#46; E&#44; Cine-MRI&#44; four-chamber view at systole showing the thickening of the lateral wall of the LV<span class="elsevierStyleInf">2</span>&#46; F&#44; Delayed enhancement&#44; four-chamber view without scar&#47;fibrosis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Outpouching of the left ventricle is a rare condition with heterogeneous causes ranging from congenital abnormalities&#44; such as diverticula or muscle bands&#44; to complications secondary to myocardial infarction&#44; such as aneurysm and pseudoaneurysm&#46; Distinguishing among these etiologies is challenging but of great clinical importance given the wide range of risks and implications involved&#46;<a class="elsevierStyleCrossRefs" href="#bib1"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="para20" class="elsevierStylePara elsevierViewall">Double chambered is a term that has been used to describe the subdivision of a ventricle as a result of anomalous septum or muscle bundle&#46; Subdivision of the left ventricular cavity is a rare cardiac anomaly compared with subdivision of the right ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Cardiac magnetic resonance imaging &#40;CMRI&#41; is useful in the assessment of associated conditions and to better understand the disease&#44; characterizing the diagnosis&#46; CMRI can demonstrate changes in the ventricular contractility&#44; presence or absence of fibrosis and is useful in the follow-up of patients with double-chambered left ventricle &#40;DCLV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;4</a></p><p id="para40" class="elsevierStylePara elsevierViewall">We describe a case of DCLV&#44; highlighting the importance of CMRI&#44; clinical evolution&#44; and outcome&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE PRESENTATION</span><p id="para50" class="elsevierStylePara elsevierViewall">A 29-year-old sedentary man presented to the emergency room an hour after developing chest pain that radiated to the inner side of the left arm&#46; The patient was administered acetylsalicylic acid and nitrate and symptoms soon improved&#46; The patient had no family history of coronary artery disease &#40;CAD&#41;&#44; had smoked a pack of cigarettes a day for the past 10 years&#44; and was obese and hypertensive &#40;140&#47;95 mmHg&#41;&#46; Physical examination revealed no cardiac murmur and the electrocardiogram &#40;EKG&#41; was normal&#44; but plasma cardiac necrosis markers were elevated&#46; Although thoracic window acquisition was difficult&#44; echocardiogram examination revealed no abnormalities and global LV function was normal&#46; After the pain had subsided&#44; the patient was discharged and directed to consult a cardiologist&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Based on the necrosis marker changes and presence of type-B pain on that day&#44; the cardiologist recommended a stress test&#44; but the patient was unable to meet the physical requirements for accurate evaluation&#46; In the absence of a stress test&#44; an invasive coronary angiography &#40;ICA&#41; was requested&#46; ICA revealed normal coronary arteries&#44; but ventriculography showed an outpouching on the left ventricle that was thought to be an aneurysm &#40;<a class="elsevierStyleCrossRef" href="#fig1">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para70" class="elsevierStylePara elsevierViewall">Further investigation was performed in a 1&#46;5-Tesla MRI scanner &#40;Avanto&#44; Siemens Medical Solutions&#44; Erlangen&#44; Germany&#41; with a four-element phased-array cardiac coil using perfusion&#44; cine-Steady-state free precession &#40;SSFP&#41; and delayed-enhancement sequences&#46; MRI results confirmed the presence of the pouch&#44; appending to the posterior and lateral wall of the left ventricle &#40;<a class="elsevierStyleCrossRef" href="#fig2">Fig&#46; 2</a>&#41;&#46; It measured 5&#46;8 cm in the long-axis view and 2&#46;4 cm in the short axis&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para80" class="elsevierStylePara elsevierViewall">As seen in <a class="elsevierStyleCrossRef" href="#fig3">Fig&#46; 3</a>&#44; the pouch was separate from the apex&#46; The wall thickness of the thinner segment of LV<span class="elsevierStyleInf">2</span> was 5 mm in end diastole&#44; a little bit less than the remaining left ventricular myocardium&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia><p id="para90" class="elsevierStylePara elsevierViewall">The majority of the pouch was found to be contractile&#46; In the short-axis view&#44; the myocardium separating both chambers and a systolic flow jet leaving the pouch and entering the primary LV chamber were noted&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The cine sequences showed normal left ventricular contraction &#40;ejection fraction 51&#37;&#41;&#46; The pouch exhibited normal systolic contraction without any regional wall motion abnormality&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">After injection of Gadolinium - diethylenetriamine penta-acetic acid &#40;Gd-DTPA&#41;&#44; the first pass perfusion in the short-axis view displayed normal myocardial perfusion&#46; Late enhancement of the short and long axes revealed no myocardial scarring&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">The patient was diagnosed with a congenital DCLV&#46; He was instructed to undergo diet and exercise and follow up with a cardiologist to ensure that symptoms and cardiac function remain under control&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para130" class="elsevierStylePara elsevierViewall">DCLV is characterized by the division of the ventricular chamber into two chambers by abnormal muscular tissue&#46; It is best differentiated from left ventricular aneurysms and pseudoaneurysms by the fact that the double-chambered ventricle exhibits contractile motion during systole&#46; Ventricular aneurysm lacks complete layering of the ventricular wall&#44; and thus expands slightly due to the increased pressure during systole&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#44;6</a></p><p id="para140" class="elsevierStylePara elsevierViewall">The differentiation between double-chambered left and right ventricles is clear as they have different pathophysiology&#46; Double-chambered right ventricle &#40;DCRV&#41; is more common and often presents with murmur and exertional dyspnea&#46; Studies have found that DCRV is associated with septal defects&#44; tetralogy of Fallot&#44; and transposition of the great arteries&#46; Conversely&#44; DCLV is commonly asymptomatic&#46; DCRV is often caused by a progressive thickening of the right ventricular septum due to the presence of anomalous muscle bundles&#46; This causes a pressure gradient&#44; and two chambers in series develop&#46; In contrast&#44; the chambers of a DCLV are in parallel and present less of a pressure gradient&#44; as both contract synchronously&#46; The DCLV etiology is less well known&#44; but the anomaly is thought to be congenital and non-progressive&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;7&#44;8</a></p><p id="para150" class="elsevierStylePara elsevierViewall">Usually&#44; DCLV is incidentally found in the course of an evaluation for other cardiovascular abnormalities&#46; As this is an extremely rare finding&#44; no definite data regarding the prognosis&#44; outcomes and potential complications&#44; such as risk of embolism&#44; of DCLV are available&#46; It is generally believed that DCLV poses little risk to the patient&#46; Treatment&#44; if any&#44; is usually guided by the presence of other associated abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;9&#44;10</a></p><p id="para160" class="elsevierStylePara elsevierViewall">The CMRI with the normal delayed enhancement images suggested that the patient had not suffered a myocardial infarction&#46; Additionally&#44; there were no signs of fibrosis on the myocardium&#44; even near the outpouching&#46; This rules out the possibility that the pouch was formed as a result of trauma or infarction&#44; and suggests that the pouch&#39;s origin is congenital&#46; Through examination of the four-chamber sequence&#44; the pouch is seen to have a fully developed myocardial wall that contracts synchronously with the rest of the myocardium&#46; During systole&#44; one area of the pouch&#39;s myocardial wall appears thinner&#44; but the delayed enhancement image verifies that the wall muscle is in fact fully developed in that region&#46; This excludes the possibility of one aneurysm&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;6&#44;11&#44;12</a></p><p id="para170" class="elsevierStylePara elsevierViewall">We believe the misdiagnosis was probably due to a poor thoracic window that did not yield proper diagnostic-quality images of this condition&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">There is not <span class="elsevierStyleItalic">too</span> much data stating the importance of other non-invasive methods but it is reasonable to assume that echocardiography and computed tomography can aid in detection of double-chambered ventricles&#46; However&#44; MRI allows a better delineation of this condition because of its higher spatial resolution and the ability for tissue characterization&#44; especially regarding the differentiation between fibrosis and normal myocardium&#44; which would not be easily achievable on echocardiography and CT&#46;</p><p id="para190" class="elsevierStylePara elsevierViewall">Because of the rarity of DCLV&#44; few data exist on treatments and outcomes&#46; Surgical excision of the accessory chamber with interposition patch reconstruction and cardiac transplant are two valid options&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;5</a></p><p id="para200" class="elsevierStylePara elsevierViewall">In the case presented&#44; normal ejection fraction and wall motion are positive signs&#44; suggesting that the patient&#39;s condition is not immediately life threatening&#44; eliminating the need for surgical intervention&#46; One concern is the possibility that a clot will form in the minor ventricle&#44; although in the patient&#39;s case good blood flow through the communication gap lessens that risk&#46; The patient was discharged and told to follow up with his cardiologist&#59; 7 months of follow up have now passed without any clinical symptoms&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos