Survival after right ventricular diverticulum caused by right ventricular rupture: Case report and brief review of the literature

Survival after right ventricular diverticulum caused by right ventricular rupture: Case report and brief review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Survival after right ventricular diverticulum caused by right ventricular rupture: Case report and brief review of the literature Hao Yu, Baolong Ding, Linlin Ji, Chunbo Zhai This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3829192/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Ventricular diverticulum can be divided into congenital and acquired diverticulum. Cardiac rupture is a rare occurrence of cardiac injury, but the mortality rate is very high. Part of cardiac rupture may form an acquired ventricular diverticulum. Here, we present a case of a 57-year-old man presenting with right ventricular diverticulum caused by traumatic ventricle rupture. Case presentation: A 57-year-old man was admitted with chest pain and dyspnea after falling from a high place. The patient's condition gradually stabilized after emergency surgery and rescue treatment measures. One week later, the patient suddenly presented with swelling of the right upper limb. Right upper extremity venous thrombosis was detected by vascular color ultrasound. Further pulmonary artery computed tomography angiography (CTA) examination revealed an upper right pulmonary artery embolism and a diverticulum in the right ventricular wall; however, no obvious diverticulum or pericardial effusion was found by echocardiography. After a thorough discussion with the cardiac surgeon, it was decided that anticoagulant therapy should be given under close monitoring. After ten days, pulmonary CTA showed that the pulmonary thrombus had disappeared, but the right ventricular diverticulum was more prominent than before, so anticoagulant therapy was stopped, but hemostatic drugs were not given. Finally, the right ventricular diverticulum gradually shrinks and heals. Conclusions Although certain imaging features exist, the missed diagnosis of occult cardiac diverticulum cannot be ignored. We learned from this case that the diagnostic value of cardiac CTA or pulmonary artery CTA for occult heart injury might be superior to that of cardiac ultrasound. Ventricular diverticulum Ventricle rupture Acquired diverticula Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The ventricular diverticulum are characterized by an outpouching of the entire ventricular wall[ 1 ], a corresponding finger-like protrusion from the internal cavity extending outside the epicardium margin[ 2 ], and a narrow connection to the cavity[ 3 ]. Depending on the amount of myocardial fibers involved, diverticula may be classified in muscular or fibrous[ 4 ]. Muscular diverticula contain all layers of the ventricular myocardium with the myocardial architecture preserved and minimal fibrous tissue[ 5 ]. Ventricular diverticulum can be divided into congenital diverticulum and acquired diverticulum. Congenital ventricular diverticulum (CVD) accounts for 0.05% of all congenital heart malformations[ 6 ]. Acquired diverticulum are usually caused by trauma, surgery, infection, and tumor. Thoracic trauma is the third most common cause of trauma and is associated with high morbidity and mortality. The incidence of cardiac injury due to blunt chest trauma ranges from 3–56%. Cardiac rupture is a rare occurrence of cardiac injury, but the death rate is very high. According to statistics, the death rate from blunt heart injury in the United States is 1/2400[ 7 ]. Here, we present a case of a 57-year-old man presenting with right ventricular diverticulum caused by traumatic ventricle rupture. Case presentation A 57-year-old man was admitted to the emergency room at our hospital due to falling from a height, in which case the patient received blunt chest trauma. The patient complained of severe chest pain with chest tightness and shortness of breath. The patient had no history of coronary heart disease. Computed tomography (CT) indicated "multiple rib fractures on both sides, left-sided hemopneumothorax, and right-sided small pleural effusion." After being transferred to the cardiothoracic surgical ward, the dyspnea worsens. Emergency bedside ultrasound indicated massive pleural effusion in the right thorax. Bilateral chest closed drainage was performed under local anesthesia. Approximately 200ml of bloody liquid and a small amount of gas were drained from the left side, while around 800ml of dark red bloody liquid was drained from the right side. Subsequently, the patient experienced palpitation and chest tightness, leading to the clamping of the right drainage tube. A transfusion of 1.5 U of suspended red blood cells was administered. Following the transfusion, the chest drainage tube was reopened, resulting in the drainage of approximately 400ml of dark red bloody fluid. At this point, the patient once again experienced chest pain and discomfort, accompanied by irritability and sweating. Blood pressure measurement indicated a reading of 75/50mmHg. Considering the active bleeding in the chest, emergency thoracoscopic hemostasis was performed on the right side. During the operation, a significant amount of bloody fluid was discovered in the chest cavity, along with the formation of blood clots. No bleeding was observed in the lungs, intercostal vessels, and diaphragm. A tear measuring 2.0cm in length was observed on the right side of the pericardium near the diaphragm. There was no activity detected in the pericardium during exploration. Although there was a small amount of blood clots, cardiac surgeons diagnosed no active bleeding, and close observation and treatment are advised for the time being. If active bleeding reoccurs, cardiac repair will be considered. Consequently, the patient was transferred to the Department of Critical Care Medicine for further treatment. After 2 days of treatment in the Department of Critical Care Medicine, the drainage fluid amounted to approximately 200ml per day. The color of the drainage fluid was light red. The patient's blood pressure, heart rate, and blood oxygen saturation remained stable. On the third day after the operation, the patient was transferred to the general surgical ward in the chest hospital. One week post-operation, swelling was observed in the right upper limb. A venous color Doppler ultrasound was conducted to detect venous thrombosis in the upper limb. Subsequently, a CTA examination of the pulmonary artery revealed a branch embolism in the right upper lobe artery (Fig. 1 A) and the presence of a right ventricular diverticulum (Fig. 1 B). However, the repeat cardiac color ultrasound detected no evident cardiac diverticulum or pericardial effusion. After consulting with the cardiac surgeon regarding the condition and treatment plan, it was decided to initiate anticoagulant treatment using low molecular weight heparin calcium, closely monitoring the patient and advising them to avoid excessive activity of the upper limbs to prevent blood clot loss. The upper limb edema resolved after one week of anticoagulation, prompting a reexamination of the pulmonary artery using CTA. The results demonstrated the disappearance of the right upper pulmonary artery thrombus (Fig. 2 A) but an enlargement of the right ventricular diverticulum (Fig. 2 B). Following further communication with the cardiac surgeon, it was decided to discontinue anticoagulant medication while temporarily withholding hemostatic drugs to prevent thrombosis. A subsequent pulmonary artery CTA review five days later revealed a significant reduction in the size of the right ventricular diverticulum (Fig. 3 ), maintaining the original treatment plan. After five days of observation, a repeat pulmonary artery CTA showed that the channel between the diverticulum and the ventricular cavity had healed, leaving only a tiny diverticulum in the ventricular wall (Fig. 4 ). Consequently, the patient was discharged and instructed to continue recovery at home. One month later, an outpatient pulmonary artery CTA confirmed complete healing of the right ventricular diverticulum (Fig. 5 ), with no apparent effusion detected in the cardiac color Doppler ultrasound. Discussion and conclusions The mechanisms of blunt trauma to the heart can be categorized as follows: direct force to the heart, compression between the sternum and spine, concussion from trauma, penetrating injuries caused by broken ribs and sternum fragments, blast injuries, and damage to the heart and great vessels. Additionally, injuries can occur due to sudden acceleration and deceleration of movement, known as the 'hydraulic hammer' or 'water hammer' effect. This effect involves the sudden compression of veins in the abdomen or extremities, which can cause the ventricles to expand. This patient experienced multiple rib fractures on both sides when they fell from a height, with the left side resulting in a punctured lung tissue causing left hemopneumothorax. The right side rib fracture did not puncture any vital organs. The mechanisms of injury that could have caused heart rupture include direct impact force on the heart, compression between the sternum and spine, trauma-induced concussion, damage from sudden deceleration of the heart and blood vessels, and the 'water hammer' effect. A combination of these mechanisms likely led to simultaneous rupture of the heart and pericardium in this patient. The rupture of the pericardium played a crucial role in the patient's survival as it allowed the blood from the heart to flow into the chest cavity, preventing cardiac tamponade and buying time to save the patient's life. However, the patient also experienced massive blood loss, leading to decreased volume and pressure in the ventricular cavity, which sealed the heartbreak after myocardial contraction and prevented further bleeding. Therefore, no significant cardiac bleeding was observed during thoracoscopic pericardial exploration. Some believe that pericardial tears may improve the survival rate by avoiding cardiac tamponade, but pleural decompression can result in massive hemothorax and increased subsequent mortality. Patients with severe chest trauma should remain vigilant for potential cardiac injuries. According to Turk and Tsokos' study, out of the 33 cases of death caused by heart damage, five individuals managed to survive for 12 hours[ 8 ]. It is possible that these victims could have avoided death if the heart damage had been promptly diagnosed and treated. Regrettably, the majority of patients with heart ruptures do not have the opportunity to reach the emergency room in time. A diverticulum is a sac-like structure that protrudes from the ventricular wall. The diameter of the connection between the sac and the cardiac chamber is smaller than the maximum diameter of the sac. Ventricular diverticula can be classified into two types: muscular and fibrous. Muscular diverticula, which are more common, have the normal three-layer structure of the heart, are not easily ruptured, are contractile, and have narrow systolic junctions. They are often associated with Cantrell syndrome. On the other hand, fibrous diverticula only consist of a fibrous layer, lack contractile function, and are prone to rupture. They are typically located at the base of the heart or under the valve annulus, which can result in aortic or mitral valve insufficiency. Approximately 63% of patients with cardiac diverticula do not exhibit any clinical symptoms, but they may also experience serious complications such as sudden death, cardiac rupture, arrhythmia, mural thrombus, embolism, and heart failure[ 9 – 12 ]. The patient in this case was admitted to our hospital due to a 10-hour injury caused by a fall from a high altitude. A right ventricular diverticulum was identified during the physical examination. Subsequently, the patient underwent puncture, thoracoscopic exploration, and thoracoscopic hemostasis. Anticoagulant therapy was initiated due to the high risk of VTE. Multiple blood clots occurred during treatment, which necessitated the continuation of anticoagulant and thrombolytic therapy. Follow-up imaging examinations such as enhanced CT and pulmonary artery CTA revealed significant enlargement of the right ventricular diverticula compared to the initial findings. After discontinuing anticoagulant therapy for a period of time, the severity of the diverticula decreased, and they were completely healed during the final discharge examination. The patient's overall health condition improved and is no longer serious. One month after discharge, the enhanced CT reexamination did not show any apparent diverticula, indicating that the diverticulum is considered to be essentially healed. Additionally, other examinations conducted on the patient did not reveal any abnormalities, and the patient's overall physical condition has substantially recovered. This suggests a close relationship between the development of the diverticulum and the occurrence of trauma, as well as the subsequent treatment. Based on our analysis, it is likely that the diverticulum in the right ventricle was caused by the patient's trauma. Although it cannot be ruled out that congenital diverticula may be worsened by trauma. Patients with asymptomatic diverticulum and no complications can be managed conservatively with regular follow-up. However, most diverticula typically require surgical intervention. Surgery is recommended for those experiencing refractory heart failure, arrhythmia, thrombosis, and embolism. Additionally, individuals with fibrous diverticula that are at risk of paradoxical movement and rupture should undergo surgery promptly. Correction of intracardiac malformations should also be considered. In cases where the diverticulum are small and have good systolic function, surgical removal may not be necessary. Interestingly, the patient's right ventricular diverticulum showed gradual healing without the need for any specific treatment. Some researchers have suggested that ventricular fibrous diverticula are formed due to congenital weakness or absence of muscular structures and stretching under cardiac chamber pressure. Imaging examinations often show that these diverticula have a pocket-like shape and are mainly composed of fibrous tissue, which is thin and non-contractile. They may also be accompanied by calcification and typically originate from the mitral valve or subaortic valve area without any association with other malformations. In this particular patient, no obvious intrapericardial hemorrhage was observed during the thoracotomy. Therefore, it is inferred that the patient experienced a strong traumatic impact, leading to myocardial contusion and pericardial rupture, resulting in acquired ventricular wall muscle weakness. The pericardial rupture causes the opposing force against the outward squeezing of blood in the ventricle to disappear. Simultaneously, due to the elasticity of myocardial fibers, the pressure in the ventricle causes it to bulge outward, forming a ventricular diverticulum. Further investigation is needed to determine if this is the true cause of diverticula development in patients. Various factors, such as heart compression between the spine and sternum, sudden fluctuations in thoracoabdominal pressure, rapid deceleration shearing, and explosion injuries, can potentially lead to heart rupture and massive intrapericardial hemorrhage, resulting in cardiac tamponade. These complications, including shock and even death, can arise from such injuries. It is worth noting that rib fractures can also directly injure the heart, even without causing penetrating injury. In fact, right heart injury is the most common form of cardiac injury, likely due to its proximity to the anterior chest wall[ 13 ]. This proximity may also explain the occurrence of diverticula in the right ventricle. Abbreviations CVD Congenital ventricular diverticulum CTA Pulmonary artery computed tomography angiography CT Computed tomography VTE Venous thromboembolism disorder. Declarations Acknowledgements We are grateful to the patients who agreed to provide the case and to the hospital for the relevant information Author contribution H. Y. drafted the manuscript C. Z.and L. J. revised it. B. D. acquired all figures. All authors read and approved the final manuscript for submission. Funding information The authors gratefully acknowledge funding support via Scientific Research Project of Health Commission of Weifang (WFWSJK-2023-003), Weifang Municipal Science and Technology Development Plan Project (2023YX011), WU JIEPING MEDICAL FOUNDATION (320.6750.2022-11-47). Availability of data and materials Not applicable. Consent for publication Not applicable. Compliance with ethical standards Conflicts of interest The authors declare that they have no competing interests. Ethics approval This study was conducted with the approval at The First Affiliated Hospital, Shandong second Medical University (Weifang People’s Hospital). The patient in this study signed an informed written consent form. References Tullu MS, Vaideeswar P, Deshmukh CT. Congenital left ventricular diverticula. Int J Cardiol. 2000;73(3):293–5. Erol C, Koplay M, Olcay A, et al. Congenital left ventricular wall abnormalities in adults detected by gated cardiac multidetector computed tomography: clefts, aneurysms, diverticula and terminology problems. Eur J Radiol. 2012;81(11):3276–81. Makkuni P, Kotler MN, Figueredo VM. Diverticular and aneurysmal structures of the left ventricle in adults: report of a case within the context of a literature review. Tex Heart Inst J. 2010;37(6):699–705. Nam KH, Kwon JY, Son GH, et al. Prenatally diagnosed left ventricular diverticulum with thoracoabdominal wall defect: a case and review of the literature. J Perinatol. 2010;30(11):760–2. Srichai MB, Hecht EM, Kim DC, et al. Ventricular diverticula on cardiac CT: more common than previously thought. AJR Am J Roentgenol. 2007;189(1):204–8. Shauq A, Agarwal,V., and, Crawley C. Congenital left ventricular diverticulum. Heart Lung Circ. 2006;15(4):272–4. Shen T, Fang H, Tang T, et al. Case report: Delayed cardiac rupture with congenital absence of pericardium after blunt trauma. Front Cardiovasc Med. 2022;9:1079670. Türk EE, Tsokos M. Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern. J Trauma. 2004;57(2):301–4. Dostálová G, et al. A congenital diverticulum of the left ventricular apex manifested by stroke and recurrent ventricular tachycardia. Cardiovasc Pathol. 2017;28:3–6. Ohlow MA, von Korn H, Lauer B. Characteristics and outcome of congenital left ventricular aneurysm and diverticulum: Analysis of 809 cases published since 1816. Int J Cardiol. 2015;185:34–45. Bhardwaj B, Kumar SA, Webel R, et al. Multimodality detection of multiple left ventricular diverticula: A case report and brief review of the literature. Echocardiography. 2019;36(1):184–8. Gocen U, Atalay A, Salih OK. A Case of Neonatal Heart Failure Caused by Left Ventricular Diverticulum: Successful ECMO Support Application. Heart Surg Forum. 2016;19(4):E189–91. Nair L, Winkle B, Senanayake E. Managing blunt cardiac injury. J Cardiothorac Surg. 2023;18(1):71. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3829192","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":265141540,"identity":"cad6691f-eaaf-4c09-a090-4752f720e2d9","order_by":0,"name":"Hao Yu","email":"","orcid":"","institution":"Affiliate Hospital of Shandong Second Medical University, Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Yu","suffix":""},{"id":265141541,"identity":"fd46ec48-2e0e-4ff7-898f-b8d2c49f16ca","order_by":1,"name":"Baolong Ding","email":"","orcid":"","institution":"Shandong Second Medical University (Weifang People’s Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Baolong","middleName":"","lastName":"Ding","suffix":""},{"id":265141542,"identity":"7cef3215-5520-49a5-a0e7-5fcdfab848ce","order_by":2,"name":"Linlin Ji","email":"","orcid":"","institution":"Shandong Second Medical University (Weifang People’s Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Linlin","middleName":"","lastName":"Ji","suffix":""},{"id":265141543,"identity":"51267e21-eba2-4881-ade2-12c0eb82a84b","order_by":3,"name":"Chunbo Zhai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYDACCQaGA4wNDIz9zMwHH5CmZWY7W7IB0VoYQFo2nOcxEyBKh/zs5ocHfu7YJrv5MIMZA0ONTTRBLYxzjhkc7D1z23jbYYa0BwzH0nIbCGlhlkgwOMzYdjsRqOW4AWPDYcJa2CTSP4C1bG5mbJMgSguPRA7Elg3MzGzEaZGQyCkA+2XGYTZmgwRi/CI/I33zh587bsv295//+OBDjQ1hLagggTTlo2AUjIJRMApwAQBt2UU/tCgF7gAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong Second Medical University (Weifang People’s Hospital)","correspondingAuthor":true,"prefix":"","firstName":"Chunbo","middleName":"","lastName":"Zhai","suffix":""}],"badges":[],"createdAt":"2024-01-02 10:14:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3829192/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3829192/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49241313,"identity":"1cb10a41-4bf3-4713-bdbe-ca4a8df28b3d","added_by":"auto","created_at":"2024-01-05 18:24:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1102307,"visible":true,"origin":"","legend":"\u003cp\u003ePulmonary artery CTA on July 7. (A) shows right upper lobe artery branch embolism. (B) shows right ventricular diverticulum.\u003c/p\u003e","description":"","filename":"FIG1.png","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/81cde5664ab9a1753097a226.png"},{"id":49241314,"identity":"76c62977-e993-4f67-a48d-26e066029018","added_by":"auto","created_at":"2024-01-05 18:24:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1182053,"visible":true,"origin":"","legend":"\u003cp\u003ePulmonary artery CTA on July 15. (A) The right upper pulmonary artery branch embolism disappeared. (B) showed that the right ventricular diverticulum was enlarged compared with before.\u003c/p\u003e","description":"","filename":"FIG2.png","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/153e3c468eefe33e69c353fe.png"},{"id":49241317,"identity":"c4c7d325-a395-4173-b1ed-3800ef4058ad","added_by":"auto","created_at":"2024-01-05 18:24:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":889807,"visible":true,"origin":"","legend":"\u003cp\u003eA follow-up pulmonary artery CTA on July 20 showed that the cardiac diverticulum was smaller than before.\u003c/p\u003e","description":"","filename":"FIG3.png","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/0421eec6447a290f338fb94d.png"},{"id":49241312,"identity":"a8d8953e-9c38-46b3-8a95-bcd5d87e7b8b","added_by":"auto","created_at":"2024-01-05 18:24:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":952789,"visible":true,"origin":"","legend":"\u003cp\u003e(A)Pulmonary artery CTA on July 24. The channel between the diverticulum and the ventricular cavity healed, and only the small diverticulum on the ventricular wall remained. (B) A follow-up CT scan one month after discharge showed no obvious diverticulum.\u003c/p\u003e","description":"","filename":"FIG4.png","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/021308e4cec2acab1d0fa7fe.png"},{"id":49242873,"identity":"9da76c80-cd3d-410b-8915-bbfdf2cec956","added_by":"auto","created_at":"2024-01-05 18:32:22","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":873601,"visible":true,"origin":"","legend":"\u003cp\u003eDuring the review one month after discharge, no right ventricular diverticulum was found on pulmonary artery CTA.\u003c/p\u003e","description":"","filename":"FIG5.png","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/b2047a1de1628dc714ae75b0.png"},{"id":55265217,"identity":"017d3ee1-b104-4f0b-917b-dc17de968587","added_by":"auto","created_at":"2024-04-25 01:59:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3740813,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3829192/v1/55e3795f-884a-4ed5-808b-f85c5de55e97.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Survival after right ventricular diverticulum caused by right ventricular rupture: Case report and brief review of the literature","fulltext":[{"header":"Background","content":"\u003cp\u003eThe ventricular diverticulum are characterized by an outpouching of the entire ventricular wall[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], a corresponding finger-like protrusion from the internal cavity extending outside the epicardium margin[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and a narrow connection to the cavity[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Depending on the amount of myocardial fibers involved, diverticula may be classified in muscular or fibrous[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Muscular diverticula contain all layers of the ventricular myocardium with the myocardial architecture preserved and minimal fibrous tissue[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Ventricular diverticulum can be divided into congenital diverticulum and acquired diverticulum. Congenital ventricular diverticulum (CVD) accounts for 0.05% of all congenital heart malformations[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Acquired diverticulum are usually caused by trauma, surgery, infection, and tumor.\u003c/p\u003e \u003cp\u003eThoracic trauma is the third most common cause of trauma and is associated with high morbidity and mortality. The incidence of cardiac injury due to blunt chest trauma ranges from 3\u0026ndash;56%. Cardiac rupture is a rare occurrence of cardiac injury, but the death rate is very high. According to statistics, the death rate from blunt heart injury in the United States is 1/2400[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHere, we present a case of a 57-year-old man presenting with right ventricular diverticulum caused by traumatic ventricle rupture.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 57-year-old man was admitted to the emergency room at our hospital due to falling from a height, in which case the patient received blunt chest trauma. The patient\u003c/p\u003e \u003cp\u003ecomplained of severe chest pain with chest tightness and shortness of breath. The patient had no history of coronary heart disease. Computed tomography (CT) indicated \"multiple rib fractures on both sides, left-sided hemopneumothorax, and right-sided small pleural effusion.\" After being transferred to the cardiothoracic surgical ward, the dyspnea worsens. Emergency bedside ultrasound indicated massive pleural effusion in the right thorax. Bilateral chest closed drainage was performed under local anesthesia. Approximately 200ml of bloody liquid and a small amount of gas were drained from the left side, while around 800ml of dark red bloody liquid was drained from the right side. Subsequently, the patient experienced palpitation and chest tightness, leading to the clamping of the right drainage tube. A transfusion of 1.5 U of suspended red blood cells was administered. Following the transfusion, the chest drainage tube was reopened, resulting in the drainage of approximately 400ml of dark red bloody fluid. At this point, the patient once again experienced chest pain and discomfort, accompanied by irritability and sweating. Blood pressure measurement indicated a reading of 75/50mmHg. Considering the active bleeding in the chest, emergency thoracoscopic hemostasis was performed on the right side.\u003c/p\u003e \u003cp\u003eDuring the operation, a significant amount of bloody fluid was discovered in the chest cavity, along with the formation of blood clots. No bleeding was observed in the lungs, intercostal vessels, and diaphragm. A tear measuring 2.0cm in length was observed on the right side of the pericardium near the diaphragm. There was no activity detected in the pericardium during exploration. Although there was a small amount of blood clots, cardiac surgeons diagnosed no active bleeding, and close observation and treatment are advised for the time being. If active bleeding reoccurs, cardiac repair will be considered. Consequently, the patient was transferred to the Department of Critical Care Medicine for further treatment. After 2 days of treatment in the Department of Critical Care Medicine, the drainage fluid amounted to approximately 200ml per day. The color of the drainage fluid was light red. The patient's blood pressure, heart rate, and blood oxygen saturation remained stable. On the third day after the operation, the patient was transferred to the general surgical ward in the chest hospital. One week post-operation, swelling was observed in the right upper limb. A venous color Doppler ultrasound was conducted to detect venous thrombosis in the upper limb. Subsequently, a CTA examination of the pulmonary artery revealed a branch embolism in the right upper lobe artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) and the presence of a right ventricular diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). However, the repeat cardiac color ultrasound detected no evident cardiac diverticulum or pericardial effusion. After consulting with the cardiac surgeon regarding the condition and treatment plan, it was decided to initiate anticoagulant treatment using low molecular weight heparin calcium, closely monitoring the patient and advising them to avoid excessive activity of the upper limbs to prevent blood clot loss. The upper limb edema resolved after one week of anticoagulation, prompting a reexamination of the pulmonary artery using CTA. The results demonstrated the disappearance of the right upper pulmonary artery thrombus (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) but an enlargement of the right ventricular diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Following further communication with the cardiac surgeon, it was decided to discontinue anticoagulant medication while temporarily withholding hemostatic drugs to prevent thrombosis. A subsequent pulmonary artery CTA review five days later revealed a significant reduction in the size of the right ventricular diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), maintaining the original treatment plan. After five days of observation, a repeat pulmonary artery CTA showed that the channel between the diverticulum and the ventricular cavity had healed, leaving only a tiny diverticulum in the ventricular wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Consequently, the patient was discharged and instructed to continue recovery at home. One month later, an outpatient pulmonary artery CTA confirmed complete healing of the right ventricular diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), with no apparent effusion detected in the cardiac color Doppler ultrasound.\u003c/p\u003e "},{"header":"Discussion and conclusions","content":"\u003cp\u003eThe mechanisms of blunt trauma to the heart can be categorized as follows: direct force to the heart, compression between the sternum and spine, concussion from trauma, penetrating injuries caused by broken ribs and sternum fragments, blast injuries, and damage to the heart and great vessels. Additionally, injuries can occur due to sudden acceleration and deceleration of movement, known as the 'hydraulic hammer' or 'water hammer' effect. This effect involves the sudden compression of veins in the abdomen or extremities, which can cause the ventricles to expand.\u003c/p\u003e \u003cp\u003eThis patient experienced multiple rib fractures on both sides when they fell from a height, with the left side resulting in a punctured lung tissue causing left hemopneumothorax. The right side rib fracture did not puncture any vital organs. The mechanisms of injury that could have caused heart rupture include direct impact force on the heart, compression between the sternum and spine, trauma-induced concussion, damage from sudden deceleration of the heart and blood vessels, and the 'water hammer' effect. A combination of these mechanisms likely led to simultaneous rupture of the heart and pericardium in this patient. The rupture of the pericardium played a crucial role in the patient's survival as it allowed the blood from the heart to flow into the chest cavity, preventing cardiac tamponade and buying time to save the patient's life. However, the patient also experienced massive blood loss, leading to decreased volume and pressure in the ventricular cavity, which sealed the heartbreak after myocardial contraction and prevented further bleeding. Therefore, no significant cardiac bleeding was observed during thoracoscopic pericardial exploration. Some believe that pericardial tears may improve the survival rate by avoiding cardiac tamponade, but pleural decompression can result in massive hemothorax and increased subsequent mortality.\u003c/p\u003e \u003cp\u003ePatients with severe chest trauma should remain vigilant for potential cardiac injuries. According to Turk and Tsokos' study, out of the 33 cases of death caused by heart damage, five individuals managed to survive for 12 hours[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is possible that these victims could have avoided death if the heart damage had been promptly diagnosed and treated. Regrettably, the majority of patients with heart ruptures do not have the opportunity to reach the emergency room in time.\u003c/p\u003e \u003cp\u003eA diverticulum is a sac-like structure that protrudes from the ventricular wall. The diameter of the connection between the sac and the cardiac chamber is smaller than the maximum diameter of the sac. Ventricular diverticula can be classified into two types: muscular and fibrous. Muscular diverticula, which are more common, have the normal three-layer structure of the heart, are not easily ruptured, are contractile, and have narrow systolic junctions. They are often associated with Cantrell syndrome.\u003c/p\u003e \u003cp\u003eOn the other hand, fibrous diverticula only consist of a fibrous layer, lack contractile function, and are prone to rupture. They are typically located at the base of the heart or under the valve annulus, which can result in aortic or mitral valve insufficiency. Approximately 63% of patients with cardiac diverticula do not exhibit any clinical symptoms, but they may also experience serious complications such as sudden death, cardiac rupture, arrhythmia, mural thrombus, embolism, and heart failure[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The patient in this case was admitted to our hospital due to a 10-hour injury caused by a fall from a high altitude. A right ventricular diverticulum was identified during the physical examination. Subsequently, the patient underwent puncture, thoracoscopic exploration, and thoracoscopic hemostasis. Anticoagulant therapy was initiated due to the high risk of VTE. Multiple blood clots occurred during treatment, which necessitated the continuation of anticoagulant and thrombolytic therapy. Follow-up imaging examinations such as enhanced CT and pulmonary artery CTA revealed significant enlargement of the right ventricular diverticula compared to the initial findings. After discontinuing anticoagulant therapy for a period of time, the severity of the diverticula decreased, and they were completely healed during the final discharge examination. The patient's overall health condition improved and is no longer serious. One month after discharge, the enhanced CT reexamination did not show any apparent diverticula, indicating that the diverticulum is considered to be essentially healed. Additionally, other examinations conducted on the patient did not reveal any abnormalities, and the patient's overall physical condition has substantially recovered. This suggests a close relationship between the development of the diverticulum and the occurrence of trauma, as well as the subsequent treatment. Based on our analysis, it is likely that the diverticulum in the right ventricle was caused by the patient's trauma. Although it cannot be ruled out that congenital diverticula may be worsened by trauma. Patients with asymptomatic diverticulum and no complications can be managed conservatively with regular follow-up. However, most diverticula typically require surgical intervention. Surgery is recommended for those experiencing refractory heart failure, arrhythmia, thrombosis, and embolism. Additionally, individuals with fibrous diverticula that are at risk of paradoxical movement and rupture should undergo surgery promptly. Correction of intracardiac malformations should also be considered. In cases where the diverticulum are small and have good systolic function, surgical removal may not be necessary. Interestingly, the patient's right ventricular diverticulum showed gradual healing without the need for any specific treatment.\u003c/p\u003e \u003cp\u003eSome researchers have suggested that ventricular fibrous diverticula are formed due to congenital weakness or absence of muscular structures and stretching under cardiac chamber pressure. Imaging examinations often show that these diverticula have a pocket-like shape and are mainly composed of fibrous tissue, which is thin and non-contractile. They may also be accompanied by calcification and typically originate from the mitral valve or subaortic valve area without any association with other malformations. In this particular patient, no obvious intrapericardial hemorrhage was observed during the thoracotomy. Therefore, it is inferred that the patient experienced a strong traumatic impact, leading to myocardial contusion and pericardial rupture, resulting in acquired ventricular wall muscle weakness. The pericardial rupture causes the opposing force against the outward squeezing of blood in the ventricle to disappear. Simultaneously, due to the elasticity of myocardial fibers, the pressure in the ventricle causes it to bulge outward, forming a ventricular diverticulum. Further investigation is needed to determine if this is the true cause of diverticula development in patients. Various factors, such as heart compression between the spine and sternum, sudden fluctuations in thoracoabdominal pressure, rapid deceleration shearing, and explosion injuries, can potentially lead to heart rupture and massive intrapericardial hemorrhage, resulting in cardiac tamponade. These complications, including shock and even death, can arise from such injuries. It is worth noting that rib fractures can also directly injure the heart, even without causing penetrating injury. In fact, right heart injury is the most common form of cardiac injury, likely due to its proximity to the anterior chest wall[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This proximity may also explain the occurrence of diverticula in the right ventricle.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCongenital ventricular diverticulum\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulmonary artery computed tomography angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVTE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVenous thromboembolism disorder.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the patients who agreed to provide the case and to the hospital for the relevant information\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH. Y. drafted the manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC. Z.and L. J. revised it.\u003c/p\u003e\n\u003cp\u003eB. D. acquired all figures. All authors read and approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge funding support via Scientific Research Project of Health Commission of Weifang (WFWSJK-2023-003), Weifang Municipal Science and Technology Development Plan Project (2023YX011), WU JIEPING MEDICAL FOUNDATION (320.6750.2022-11-47).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with the approval at The First Affiliated Hospital, Shandong second Medical University (Weifang People\u0026rsquo;s Hospital). The patient in this study signed an informed written consent form.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTullu MS, Vaideeswar P, Deshmukh CT. Congenital left ventricular diverticula. Int J Cardiol. 2000;73(3):293\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErol C, Koplay M, Olcay A, et al. Congenital left ventricular wall abnormalities in adults detected by gated cardiac multidetector computed tomography: clefts, aneurysms, diverticula and terminology problems. Eur J Radiol. 2012;81(11):3276\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakkuni P, Kotler MN, Figueredo VM. Diverticular and aneurysmal structures of the left ventricle in adults: report of a case within the context of a literature review. Tex Heart Inst J. 2010;37(6):699\u0026ndash;705.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam KH, Kwon JY, Son GH, et al. Prenatally diagnosed left ventricular diverticulum with thoracoabdominal wall defect: a case and review of the literature. J Perinatol. 2010;30(11):760\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrichai MB, Hecht EM, Kim DC, et al. Ventricular diverticula on cardiac CT: more common than previously thought. AJR Am J Roentgenol. 2007;189(1):204\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShauq A, Agarwal,V., and, Crawley C. Congenital left ventricular diverticulum. Heart Lung Circ. 2006;15(4):272\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen T, Fang H, Tang T, et al. Case report: Delayed cardiac rupture with congenital absence of pericardium after blunt trauma. Front Cardiovasc Med. 2022;9:1079670.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026uuml;rk EE, Tsokos M. Blunt cardiac trauma caused by fatal falls from height: an autopsy-based assessment of the injury pattern. J Trauma. 2004;57(2):301\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDost\u0026aacute;lov\u0026aacute; G, et al. A congenital diverticulum of the left ventricular apex manifested by stroke and recurrent ventricular tachycardia. Cardiovasc Pathol. 2017;28:3\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhlow MA, von Korn H, Lauer B. Characteristics and outcome of congenital left ventricular aneurysm and diverticulum: Analysis of 809 cases published since 1816. Int J Cardiol. 2015;185:34\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhardwaj B, Kumar SA, Webel R, et al. Multimodality detection of multiple left ventricular diverticula: A case report and brief review of the literature. Echocardiography. 2019;36(1):184\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGocen U, Atalay A, Salih OK. A Case of Neonatal Heart Failure Caused by Left Ventricular Diverticulum: Successful ECMO Support Application. Heart Surg Forum. 2016;19(4):E189\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair L, Winkle B, Senanayake E. Managing blunt cardiac injury. J Cardiothorac Surg. 2023;18(1):71.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ventricular diverticulum, Ventricle rupture, Acquired diverticula","lastPublishedDoi":"10.21203/rs.3.rs-3829192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3829192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVentricular diverticulum can be divided into congenital and acquired diverticulum. Cardiac rupture is a rare occurrence of cardiac injury, but the mortality rate is very high. Part of cardiac rupture may form an acquired ventricular diverticulum. Here, we present a case of a 57-year-old man presenting with right ventricular diverticulum caused by traumatic ventricle rupture.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 57-year-old man was admitted with chest pain and dyspnea after falling from a high place. The patient's condition gradually stabilized after emergency surgery and rescue treatment measures. One week later, the patient suddenly presented with swelling of the right upper limb. Right upper extremity venous thrombosis was detected by vascular color ultrasound. Further pulmonary artery computed tomography angiography (CTA) examination revealed an upper right pulmonary artery embolism and a diverticulum in the right ventricular wall; however, no obvious diverticulum or pericardial effusion was found by echocardiography. After a thorough discussion with the cardiac surgeon, it was decided that anticoagulant therapy should be given under close monitoring. After ten days, pulmonary CTA showed that the pulmonary thrombus had disappeared, but the right ventricular diverticulum was more prominent than before, so anticoagulant therapy was stopped, but hemostatic drugs were not given. Finally, the right ventricular diverticulum gradually shrinks and heals.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAlthough certain imaging features exist, the missed diagnosis of occult cardiac diverticulum cannot be ignored. We learned from this case that the diagnostic value of cardiac CTA or pulmonary artery CTA for occult heart injury might be superior to that of cardiac ultrasound.\u003c/p\u003e","manuscriptTitle":"Survival after right ventricular diverticulum caused by right ventricular rupture: Case report and brief review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-05 18:24:17","doi":"10.21203/rs.3.rs-3829192/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b778b7c9-52d3-4173-84cd-fad93ed14e6b","owner":[],"postedDate":"January 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-24T10:59:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-05 18:24:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3829192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3829192","identity":"rs-3829192","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}