DOI:10.2214/AJR.07.3586
AJR 2008; 190:W375
© American Roentgen Ray Society
Reply
Monvadi B. Srichai,
Colin K. L. Phoon and
Jill E. Jacobs
New York University School of Medicine, New York, NY 10016
WEB—This is a Web exclusive article.
We thank Drs. Kantarci, Olgun, and Duran
[1] for their interest in our
article, "Ventricular Diverticula on Cardiac CT: More Common Than
Previously Thought" [2],
and for having raised the diagnostic consideration of closed muscular
ventricular septal defect (VSD) for defects noted in the ventricular septum.
We also considered this in the differential diagnosis of our cases with
outpouchings occurring along the interventricular septum.
We have reviewed our cases with a pediatric cardiologist familiar with echo
cardiographic and angiographic appearances of closed muscular VSD. There are
several characteristics of closed muscular VSD that were not observed in our
patient population. First, none of our patients had a history of VSD or murmur
in childhood, which, given the size of our defects, would be expected. Second,
most muscular VSDs have been reported in the mid septum
[3,
4], and they are less common in
the posterior (inferior) septum. In contrast, the cases in our series
frequently had outpouchings located in the inferior septum, often in close
approximation with the right ventricular (RV) insertion point.
Third, unlike spontaneous closure of membranous VSDs, which
characteristically may develop an aneurysmal segment, spontaneous closure of
muscular VSDs usually leaves no residual myocardial defect notable on
echocardiography. However, the natural history of spontaneous closure of
muscular VSD suggests that the closure process begins on the RV side and
progresses toward the left ventricular (LV) side
[3]. Given the high spatial
resolution and unlimited imaging planes afforded by cardiac CT and MRI, we
acknowledge that such small residual defects along the LV myocardium may now
be imaged and recognized. In fact, we are now in the process of studying this
issue.
Clinically, the distinction between ventricular diverticula and
spontaneously closed muscular VSDs is not important because patient man age
ment would not change. However, even if all of the outpouchings with a septal
location were presumed to be related to spontaneously healed muscular VSD, our
calculated prevalence of nonseptal ventricular diverticula would be 0.7%,
which is nearly double the highest previously reported prevalence of 0.4% in
an autopsy series of patients who had died of cardiac disease
[5]. We thank the authors
[1] for raising the
consideration of spontaneously closed muscular VSD as a potential cause of
outpouchings occurring in the interventricular septum.
References
- Kantarci M, Olgun H, Duran C. Is it ventricular diverticulum or
closed muscular ventricular septal defect? (letter)
AJR 2008;190
:[web] W374[Free Full Text]
- Srichai MB, Hecht EM, Kim DC, Jacobs JE. Ventricular diverticula on
cardiac CT: more common than previously thought. AJR2007; 189:204
-208[Abstract/Free Full Text]
- Hiraishi S, Agata Y, Nowatari M, et al. Incidence and natural
course of trabecular ventricular septal defect: two-dimensional
echocardiography and color Doppler flow imaging study. J
Pediatr 1992; 120:409
-415[CrossRef][Medline]
- Ramaciotti C, Vetter JM, Bornemeier RA, Chin AJ. Prevalence,
relation to spontaneous closure, and association of muscular ventricular
septal defects with other cardiac defects. Am J
Cardiol 1995; 75:61
-65[CrossRef][Medline]
- Bankl H. Congenital malformations of the heart and great
vessels: synopsis of pathology, embryology, and natural history.
Baltimore, MD: Urban and Schwarzenberg, 1977
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