Eur J Cardiothorac Surg 1999;15:864-866
© 1999 Elsevier Science NL
Left ventricular hemangioma
E. Manassea,
F. Nicolinia,
R. Canzianib,
R. Gallottia
a Cardiac Surgery Department, Istituto Clinico Humanitas, Via Manzoni 56, Rozzano 20089 Milan, Italy
b Cardiology Department, Azienda Ospedaliera S. Antonio Abate, Gallarate, Italy
Received 13 January 1999;
received in revised form 10 March 1999;
accepted 16 March 1999.
Corresponding author. Tel.: +39-02-8224-4601; fax: +39-02-8224-4691
e-mail: eric.manasse{at}humanitas.it
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Abstract
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Cardiac hemangiomas are rare, primary benign cardiac tumors. The authors report their experience of diagnosis and treatment of an hemangioma localized into the left ventricle. The tumor could be successfully resected and there is no recurrence at 1 year follow-up.
Key Words: Cardiac hemangioma • Left ventricle • Surgery
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Introduction
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The large majority of cardiac tumors are benign, only 30% being histologically malignant. Metastatic involvement of the heart is about 30 times more frequent than primary cardiac tumors in autopsy series. Primary cardiac tumors are present in every age group with a modest female predominance [1]. Among these, cardiac hemangiomas are vascular tumors, composed either by capillaries or cavernous channels and their localization to the heart is extremely rare [2,3]. Diagnosis is usually delayed, and requires multiple investigations. The majority of patients present with two distinct clinical pictures, not specific for tumor: CHF and thromboembolism with related symptoms [4]. The tumor may also present as an incidental finding on chest X-ray in a patient with asymptomatic murmur. Long-term prognosis of cardiac tumors depends on the invasiveness of the mass and the possibility of its excision [5].
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1. Case report
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A 75-year-old white female was admitted to our division because of the presence of a systo-diastolic aortic murmur. She had a history of bradiarrhytmia and atrial flutter which lead to the implant of a VVI pace-maker. She had been treated with oral anticoagulants for the last 3 years because of an episode of popliteal embolism resolved with a Fogarty procedure. Sedimentation rate was within the normal range. The transthoracic and transesophageal echocardiogram showed a polipoid mass, 3x3 cm, in an otherwise normal left ventricle in the presence of a mild mitro-aortic regurgitation (Fig. 1)
. The base of the mass was localized on the medial portion of the posterolateral wall, distal to the implant of the posteromedial papillary muscle. Infiltration of the myocardial wall was excluded. Coronary angiograms showed normal coronary arteries and a contrast blush, arising in the distribution territory of the circumflex coronary artery, suggestive of a neovascularization protruding into the left ventricle. No other cardiovascular abnormalities were present, nor were other hemangiomas. Through a median sternotomy and with the aid of hypothermic cardiopulmonary bypass with bicaval cannulation and cardioplegic arrest, the left ventricle was inspected through the mitral valve. The mass appeared to be localized under the posterior commissure. Therefore, a transventricular apical approach was preferred. A multilobular mass, which appeared pink and translucid, could be successfully excised. The size was 3x1x1 cm, and its implant base was parallel to the lateral margin of the posterior papillary muscle. The aortic clamping time was 44 min; the recovery was uneventful. The histological examination disclosed capillary hemangioma (Fig. 2)
. At 1 year follow-up, the patient is in NYHA Class I and the echocardiogram shows no recurrence of the tumor.
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Fig. 1. Transesophageal echocardiogram (transgastric view; short axis) revealing the neoformation (arrows) in the left ventricle.
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Fig. 2. Immunohistochemical staining (CD34): capillaries lined with endothelium are surrounded by connective stroma and fibroblasts.
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2. Discussion
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Cardiac hemangiomas represent rare non-myxomatous benign tumors of the heart, which are more frequently located into the anterior wall of the right ventricle and less likely to be found on the lateral wall of the left ventricle. More often, they are nodular and isolated. The widespread use of non-invasive techniques has contributed to early detection of cardiac tumors: echocardiography has proved to be very helpful to predict the etiology of most intracavitary masses, computed tomography to evaluate the extracardiac extension of the tumor while magnetic resonance imaging establishes the amount of myocardial involvement. Compression, obstruction, effusion and bleeding with relative clinical picture may be the responsible mechanism for the symptoms, depending on the size, invasiveness and location of the tumor [6]. Cardiac hemangiomas may be radically resected with excellent surgical results. The natural story is unpredictable; for this reason surgical intervention under cardiopulmonary bypass is mandatory, though the excision may be incomplete even in these rare benign tumors.
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References
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- Abad C., Campo E., Estruch R., Condom E., Barriuso C., Tassies D., Pare J.C. Cardiac hemangioma with papillary endothelial hyperplasia: report of a resected case and review of the literature. Ann Thorac Surg 1990;49(2):305-308.[Abstract]
- Burke A., Johns J.P., Virmani R. Hemangiomas of the heart. A clinicopathologic study of ten cases. Am J Cardiovasc Pathol 1990;3(4):283-290.[Medline]
- Pigato J.B., Subramanian V.A., McCaba J.C. Cardiac hemangioma. A case report and discussion. Tex Heart Inst J 1998;25(1):83-85.[Medline]
- Perchinsky M.J., Lichtenstein S.V., Tyers G.F.O. Primary cardiac tumors. Cancer 1997;79(9):1809-1815.[Medline]
- Galli R., Albanese S., Pilato E., Pacini D., Longo M., Fattori R., Ferlito M., Capecchi V., Cagnetti D., Alampi G., Berti E., Pierangeli A. The surgical treatment of a rare primary cardiac tumor: hemangioma. A report of 2 cases. Cardiologia 1997;42(1):89-93.[Medline]
- Brizard C., Latremouille C., Jebara V., Acar C., Fabiani J.N., Deloche A., Carpentier A. Cardiac hemangiomas. Ann Thorac Surg 1993;56:390-394.[Abstract]
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