Abstract
A right ventricular cardiac tumour was incidentally detected in a 50-year-old woman during medical check-up. Transthoracic echocardiography, computed tomography and magnetic resonance imaging revealed that the right ventricular tumour was widely attached to the free wall of the right ventricle and extended to the right ventricular outflow tract. The tumour was excised surgically, and the postoperative course was uneventful. Histological examination revealed that the tumour was a cardiac haemangioma.
Keywords: Cardiac haemangioma, Cardiac Tumour, Surgical resection
INTRODUCTION
Haemangioma presenting as a primary cardiac tumour is extremely rare, accounting for only 2.8% of the cases [1]. We present a case of right ventricular haemangioma that originated from the anterior free wall of the right ventricle.
CASE REPORT
A 50-year-old female patient was admitted to our department with a diagnosis of cardiac tumour; however, transthoracic echocardiography 13 years ago showed no heart tumour. Transthoracic echocardiography revealed a right ventricular tumour (maximum longitudinal diameter 36 mm; maximum transverse diameter 16 mm). Computed tomography showed a tumour with a wide stalk arising from the anterior free wall of the right ventricle and extending to the right ventricular outflow tract. 18F-fluorodexyglucose (18F-FDG) positron emission tomography (FDG-PET) showed increased 18F-FDG uptake in the tumour with a maximum standardized uptake value (SUVmax) of 2.3. Magnetic resonance imaging (MRI) revealed hyperintensity in the tumour on T2-weighted images. Furthermore, T1-weighted fast gradient-echo echo train perfusion imaging showed enhancement and progressive centripetal fil-in (Fig. 1).
Figure 1:
T1-weighted fast gradient-echo, echo train perfusion imaging following injection of gadolinium. (A) Thirty seconds after the gadolinium administration (arrow). (B) Sixty seconds after gadolinium administration (arrow). (C) The mass filled in late phase of gadolinium first-pass perfusion due to delayed venous filing (arrow).
Surgery was performed via a median sternotomy, with cardiopulmonary bypass established between the ascending aorta and both venae cavae. However, epicardial echocardiography could not precisely locate the tumour’s stalk. Therefore, we decided to visualize it through the tricuspid and pulmonary valves. After the aorta was clamped and antegrade cardioplegia was administered, the pulmonary artery was opened with a longitudinal incision, revealing the tumour below the pulmonary valve (Fig. 2A). It was also identified in the right ventricle through the tricuspid valve after right atriotomy (Fig. 2B). The tumour was excised from the surrounding tissue through the pulmonary and tricuspid valves, since the tumour was well-circumscribed. The portion of the tumour’s stalk on the right ventricle was excised along with the tumour. Analysis of a frozen section helped in the diagnosis of the cardiac haemangioma. Subsequently, the defect of the right ventricle was closed with a bovine pericardial patch configured to fit the defect (Fig. 2C). The incisions of the main pulmonary artery and the right atriotomy were closed with a continuous polypropylene suture. The patient was weaned from cardiopulmonary bypass with inotropic support. An intraoperative transoesophageal echocardiogram showed no pulmonary regurgitation. The postoperative course was uneventful. The postoperative pathological diagnosis was a mixed cavernous and capillary type cardiac haemangioma. Five months after the operation, no recurrence has occurred, according to repeat echocardiogram. After discharge, we plan to perform echocardiography every 6 months.
Figure 2:
Intraoperative findings showed the tumour adhered to the anterior right ventricular free wall. (A) The tumour as shown below the pulmonary valve. (B) The tumour as shown through the tricuspid valve (circle). (C) The defect of the right ventricular free wall was closed with bovine pericardial patch (arrow).
DISCUSSION
Approximately 75% of all cardiac tumours are histologically benign. Most benign cardiac tumours are myxoma, and cardiac haemangioma constitutes only 2.8% of primary cardiac tumours [1].
According to recent reports, the excellent contrast resolution and multiplanar capability of MRI allows qualitative diagnosis and optimal anatomical evaluation of any cardiac tumour. Here, MRI showed haemangioma, with marked high intensity on T2-weighted imaging and enhancement on T1-weighted imaging [2]. MRI is useful for histological diagnosis of cardiac tumours. However, for cardiac malignancies (malignant fibrous histiocytoma and lymphoma), which may have similar imaging findings to those of haemangiomas, adding another modality will lead to accurate preoperative diagnosis. FDG-PET is useful for determining the malignancy or benignity of cardiac tumour. Rahbar et al. [3] advocated using FDG-PET to diagnose malignancies with a cut-off SUVmax of 3.5. According to their report, malignant cardiac tumours typically exhibit a high 18F-FDG uptake, and their SUVmax is 5–16. Here, the SUVmax was 2.3, strongly suggesting a benign tumour. MRI and FDG-PET findings preoperatively helped to predict that the tumour was likely to be a haemangioma. However, because of the possibility of pathological misdiagnosis, and the unpredictability of a cardiac haemangioma’s natural history [4], we decided to perform a resection. Cardiac haemangiomas prognosis is usually favourable; however, late recurrence has recently been reported [5]. Therefore, the patient is required to undergo long-term follow-up.
ETHICS STATEMENT
The patient gave her consent for the publication of this case report.
Conflict of interest: none declared.
Reviewer information
Interactive CardioVascular and Thoracic Surgery thanks Paolo Nardi and the other, anonymous reviewer for their contribution to the peer review process of this article.
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