Ann Thorac Surg 2001;71:345-347
© 2001 The Society of Thoracic Surgeons
Case report
Surgical treatment of a hemangioma of the mitral valve
Scott W. Nye, MDa,
David A. Orsinelli, MDb,
Peter B. Baker, MDc,
David A. Brown, MDa
a Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
b Department of Cardiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
c Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
Accepted for publication April 1, 2000.
Address reprint requests to Dr Brown, Ohio State University Hospital, N825 Doan Hall, 410 W 10th Ave, Columbus, OH 43210
e-mail: brown-4{at}medctr.osu.edu
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Abstract
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Hemangioma of the heart is a rare lesion, representing % to 10% of benign cardiac tumors. Hemangioma of the mitral valve has been reported previously in one autopsy case report. We describe the excision and repair of a hemangioma of the mitral valve in a 33-year-old African-American woman.
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Introduction
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Primary tumors of the heart are rare. Benign tumors account for 72% of all primary cardiac tumors, and hemangioma accounts for 5% to 10% of benign tumors [1]. Hemangiomas are usually asymptomatic but have been reported to cause arrhythmias and pericardial effusions, both of which have been associated with sudden death. Other symptoms have included dyspnea on exertion, congestive heart failure, pseudoangina, outflow tract obstruction, and coronary insufficiency [1–4]. Echocardiography usually reveals the mass, and cardiac catheterization may confirm a specific diagnosis for hemangioma due to tumor vascularity [2].
A healthy 33-year-old African-American woman was referred by her obstetrician for evaluation of occasional palpitations that began at the end of the first trimester of her fourth pregnancy. She also complained of "chest tightness" that occurred irrespective of activity level and would typically last for 30 minutes with each episode. No symptoms were elicited of edema, orthopnea, paroxysmal nocturnal dyspnea, syncope, or fatigue beyond that which she considered normal for her pregnancy. Her medical history was significant only for three previous uncomplicated term pregnancies. She was not taking any medications at the time of her initial presentation.
Cardiac examination showed a normal S1 and S2, regular rhythm with a soft murmur heard at the left sternal border. The cardiomediastinal silhouette and pulmonary vasculature were within normal limits on the chest roentgenogram. Electrocardiogram showed a normal sinus rhythm with occasional premature supraventricular complexes.
A surface echocardiogram, obtained at the time of her initial visit, was significant for mild mitral valve prolapse with a focal thickening detected on the anterior leaflet. Her ejection fraction was estimated to be 65% with no other findings noted. A follow-up transesophageal echocardiogram was obtained approximately 1 month later. The mass was again demonstrated and was noted to be attached to the base of the anterior mitral valve leaflet or possibly to the annulus fibrosis (Fig 1). The mass was nonmobile and there was no prolapse of the valve.
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Fig 1. Transesophageal echocardiogram demonstrating tumor (arrow) attached to the base of the anterior mitral valve leaflet. (LA = left atrium; LV = left ventricle.)
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We decided to repeat an echocardiogram after her delivery. If the mass had not changed, surgical excision would at least be considered and would certainly be indicated if there were any enlargement of the lesion. A repeat echocardiogram was obtained approximately 1 month after an uncomplicated delivery, and this demonstrated an interval increase in the mitral valve mass. In addition, she now had 1+ mitral regurgitation. In light of these new findings, we believed that surgical excision of the lesion was indicated.
Due to the patient’s young age, cardiac catheterization was not considered necessary for ruling out coronary disease. In vascular tumors, catheterization may reveal a tumor blush, but this possible diagnosis was not considered at the time. We did not think that computed tomography or magnetic resonance imaging would offer information relevant to the decision whether or not to operate.
The patient was taken to the operating room 1 month later for elective resection of the lesion. A median sternotomy was made and a standard lateral left atriotomy was performed. Gross inspection demonstrated a gray-white marble-shaped 1 cm mass with a firm consistency that was raised over the annulus and anterior mitral valve leaflet. This was excised sharply en bloc from the anterior leaflet of the mitral valve, across the annulus, and including a rim of tissue from the adjacent left atrium. The lesion appeared fairly well circumscribed although not encapsulated.
Frozen section demonstrated the lesion to be that of a benign stromal type tumor with an undefined cell type. All margins were negative for tumor and it was felt that an adequate excision had been performed. The anterior leaflet defect was repaired using a dime-sized piece of native pericardium sutured in place using a running 4-0 Prolene (Ethicon, Somerville, NJ) suture. After weaning easily from cardiopulmonary bypass, an intraoperative echocardiogram was performed which demonstrated a normal appearing mitral valve with only trivial mitral regurgitation. The patient had an uncomplicated recovery and was discharged home on postoperative day 3. Final pathology revealed a benign cavernous hemangioma of the anterior leaflet of the mitral valve (Fig 2). Follow-up transesophageal echocardiography at 1 year demonstrated no recurrence of the mass and trivial mitral valve regurgitation.
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Fig 2. Histologic section of mitral valve cavernous hemangioma, showing large ectatic vascular channels, surrounded by fibrous connective tissue. (Weigert’s elastic stain, x25.)
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Comment
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Hemangiomas of the heart are rare, with only 37 reported cases involving surgical treatment. These were located throughout the heart, including the pericardium, epicardium, intraventricular, and intraatrial locations. The only previously reported case of a hemangioma of the mitral valve was found at autopsy on the posterior leaflet of the mitral valve of a 69-year-old man. No cardiac symptomatology was found in review of this patient’s medical records [1, 4].
Grossly, hemangiomas typically appear red with an occasional blue coloring, although this hemangioma had a gray-white appearance. Histologically, hemangiomas are benign tumors that demonstrate a morphology similar to that of blood vessels with an interspersed connective tissue stroma. They are typically well demarcated but not encapsulated [1]. The lack of necrosis or mitotic activity and the presence of only a mild degree of cellular atypia have been used as criteria for a benign histologic diagnosis [2]. They are usually of little clinical significance unless located in the brain or the cardiovascular system. The tumors are usually located first by echocardiography and the results of surgical resection have generally been excellent [1–5]. Of 37 reports of surgically resected cardiac hemangiomas, none has primarily involved the mitral valve, and there is only one reported case of angiosarcoma developing 7 years after the excision [1, 2, 6].
In this case, we believed that treatment was best postponed due to the patient’s pregnancy. After her pregnancy, the mass demonstrated an interval increase in size over 7 months. This was accompanied by an increase in mitral regurgitation, and we therefore were compelled to proceed with surgical treatment. Removal of the mass has resulted in lasting improvement of her mitral valve function, although she still complains of occasional chest tightness and palpitations, which are presumably unrelated to the hemangioma. This would suggest that the tumor was an incidental finding.
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References
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Burke A, Virmani R. Tumors of the heart and great vessels. In: Rosai J, Sobin LH, eds. Atlas of tumor pathology, 3rd series, fascicle 16. Washington, DC: Armed Forces Institute of Pathology, 1996:80–6.
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Burke A., Johns J.P., Virmani R. Hemangiomas of the heart. Am J Cardiovasc Pathol 1991;13:283-290.
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Brizard C., Latremouille C., Tabara V., et al. Cardiac hemangiomas. Ann Thorac Surg 1993;56:390-394.[Abstract/Free Full Text]
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McAllister HA, Fenoglic JJ Jr. Tumors of the cardiovascular system. In: Firminger HI, ed. Atlas of tumor pathology, 2nd series, fascicle 15. Washington, DC: Armed Forces Institute of Pathology, 1978:46–52.
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Murphy M.C., Sweeney M.S., Putnam J.B., et al. Surgical treatment of cardiac tumors: a 25-year experience. Ann Thorac Surg 1990;49:612-618.[Abstract/Free Full Text]
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Chalet Y., Mace L., Frac B., Neveux J.Y., Lancelin B. Angiosarcoma 7 years after surgical excision of histiocytoid haemangioma in the left atrium. Lancet 1993;341:12.
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Abstract
Introduction
