A left ventricular diverticulum is defined as an outpunching structure that contains endocardium, myocardium and pericardium and displays normal contraction. They are distinguished from the aneurysms which do not contract, have a fibrous wall and exhibit paradoxical motion. Earlier studies report a prevalence of diverticula in 0.4% or 3% of 750 cardiac necropsy cases [3, 4]. They are congenital (in absence of history of injured myocardium), asymptomatic (except for rare cases of ventricular tachycardia), and most of them are placed in the apex . There is no consensus about the treatment of this ventricular anomaly and the management should be tailored to the clinical characteristics of each patient, taking into consideration the onset of potential complications (embolization, rupture, ventricular arrhythmias) . The surgical treatment consists of an excision and placement of a patch.
During a transapical transcatheter aortic valve replacement, the apex is prepared with two purse-string sutures and then punctured in order to introduce the delivery system. Thus, in the presence of a diverticulum without intraluminal thrombi, and in the absence of good alternative vascular and accesses, the transapical approach appears to be adequate in order to treat, simultaneously, both the apical diverticulum and the aortic valve stenosis.
In our experience, we prepared two larger pledgeted purse-string sutures in order to detect good thick myocardium surrounding the diverticulum: using this stratagem, part of the diverticulum was successfully excluded when the sutures were tied and we did not experienced apical bleeding.
With regards to the postoperative management, we did not change our protocols but we performed a computed tomography scan to visualize the resulting apical anatomy. In conclusion, TAVR procedures can be safety and efficacy performed through a left ventricular apical diverticulum, in the absence of intraluminal thrombi.