Premature ventricular complexes from a left ventricular diverticulum: a case report

This is a case of a 54-year-old Asian male with frequent symptomatic and drug-refractory premature ventricular complexes (PVCs) (Panel 1) undergoing an electrophysiology study. Activation mapping of the left ventricle revealed the earliest myocardial activation (13 ms prior to QRS begin) close to a fluoroscopic protrusion of the basal-lateral wall (Panel 2). We excluded an ischaemic aneurism or coronary stenosis (Panel 3) but could not sufficiently depict the structure (Panel 4). Contrast-enhanced computed tomography revealed a large left ventricular diverticulum (LVD) with a narrow ostium (Panel 5). The muscle and thin fibrous LVD sleeves were resected en bloc (Panel 6A) and the remaining margins were coagulated prior to a plastic repair (Panel 6B). The PVCs diminished immediately and antiarrhythmic drugs were discontinued. No PVCs were detected at 1- and 3-month follow-ups and the patient remained asymptomatic. The LVD incidence is 0.04–0.4% but can reach 2.2% with the improved imaging technology. This case underlines the importance of LVD suspicion during the EP study in order to avoid the risks associated with ablation in a thin trabeculated diverticulum. Careful imaging is mandatory in such cases and surgical resection (with coagulation of the wound-borders Supplementary material online, Video S1) can eliminate both PVCs and possible LVD complications.

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