Ann Thorac Surg 2009;87:e54-e56. doi:10.1016/j.athoracsur.2009.03.005
© 2009 The Society of Thoracic Surgeons
Case Reports
Pericardial Hemangioma Taking Origin From the Posterior Wall of the Left Atrium
Jude Ediae, MDa,
Philip S. Lim, MDb,*,
V. Paul Addonizio, MDc,
Emanuel Kostacos, MDd,
Karen Bell, MDe,
Harold I. Litt, MD, PhDf
a Department of Internal Medicine, Abington Memorial Hospital, Abington
b Department of Radiology, Abington Memorial Hospital, Abington, Pennsylvania
c Department of Cardiothoracic Surgery, Abington Memorial Hospital, Abington, Pennsylvania
d Department of Cardiology, Abington Memorial Hospital, Abington, Pennsylvania
e Department of Pathology, Abington Memorial Hospital, Abington, Pennsylvania
f Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Accepted for publication March 5, 2009.
* Address correspondence to Dr Lim, Department of Radiology, Abington Memorial Hospital, 1200 Old York Rd, Abington, PA 19001 (Email: plim{at}amh.org).
 |
Abstract
|
|---|
We present a rare case of a pericardial hemangioma taking origin from the posterior wall of the left atrium and compressing the surrounding structures. Contrast cardiac magnetic resonance imaging preoperatively established the diagnosis, and computed tomographic findings helped in the management of this patient.
|
Introduction
|
|---|
Cardiac hemangioma is a rare mass that can cause a wide range of symptoms. Histologically, they are composed of vascular channels of various sizes. Tissue characterization and surgical planning can be confidently performed by contrast magnetic resonance imaging and computed tomography.
A 75-year-old man was referred to a cardiologist for evaluation of a new murmur. His past medical history included hyperlipidemia, obstructive sleep apnea, and lower extremity deep venous thrombosis 17 years prior. A transthoracic echocardiogram showed normal left ventricular function, mild aortic stenosis, and a mass that was believed to be located in the left atrium.
Contrast cardiac magnetic resonance imaging revealed a mass with a high signal on T2-weighted imaging, and nodular areas of enhancement early after contrast administration with filling in on delayed images (Fig 1). Externally the mass compressed the posterior wall of the left atrium, but it had nonaggressive features, including well-circumscribed borders without macroscopic invasion of the adjacent structures. A diagnosis of pericardial hemangioma was confidently made based on the characteristic imaging findings. The patient was first advised against surgery because of its benign radiologic diagnosis. A second surgical opinion prompted the use of contrast cardiac computed tomography to define the surrounding borders more clearly, revealing compression of the great cardiac vein (Fig 2).
View larger version (161K):
[in this window]
[in a new window]
|
Fig 1. Magnetic resonance imaging: (A) Dark-blood electrocardiographic-triggered axial T2-weighted image shows hyperintense mass (arrows) with smooth, sharply demarcated borders compressing posterior wall of left atrium and right atrium. (B) Frame from steady state-free precession cine magnetic resonance image acquisition in the vertical long-axis view shows the mass compressing the wall of the left atrium (arrows). (C) Axial T1-weighted imaging with fat saturation early after gadolinium-diethylenetriaminepentaacetic acid administration shows nodular enhancement throughout mass (arrows). (D) Inversion-recovery prepared four-chamber image obtained 15 minutes after contrast administration shows delayed filling in of the entire mass (arrows).
|
|
View larger version (121K):
[in this window]
[in a new window]
|
Fig 2. Computed tomographic scan showing four-chamber view of mass (thick arrows) compressing great cardiac vein (thin arrows). A few nodular areas of enhancement are seen in other portions of the mass (not shown).
|
|
At elective surgery, the mass was taken origin from the posterior wall of the left atrium, requiring reconstruction of the left atrial wall. Final pathology confirmed the diagnosis of a benign hemangioma weighing 66 g (Figs 3 and 4).
View larger version (179K):
[in this window]
[in a new window]
|
Fig 3. Gross pathologic photograph showing red, soft-tissue mass with one surface demonstrating grossly adherent atrial wall.
|
|
View larger version (149K):
[in this window]
[in a new window]
|
Fig 4. Microscopic histology of stained section shows a vascular neoplasm composed of multiple dilated vascular channels of varying sizes. Vascular spaces contain blood and organized thrombus and are lined by bland attenuated endothelial cells. The appearance is characteristic of a hemangioma. (Hematoxylin & eosin; x100.)
|
|
|
Comment
|
|---|
Cardiac hemangiomas are rare. They comprise only 5% to 10% of benign primary cardiac tumors and 2% of all cardiac tumors [1, 2]. They tend to grow slowly but may eventually compress cardiac structures and cause hemodynamic compromise. Clinical presentation can range from no symptoms to dyspnea, chest pain, conduction abnormalities, arrhythmias, pericardial effusion, and tamponade [3, 4].
The magnetic resonance imaging features of cardiac hemangioma were recently described [5, 6]. In our case, the magnetic resonance imaging established the preoperative diagnosis. Furthermore, computed tomography was helpful in surgical planning because of its submillimeter spatial resolution, identifying mass effect on adjacent structures, and more importantly demonstrating that the pericardial wall had not been violated, which guided the conduct of surgery. The computed tomographic scan did not reveal any foci of calcifications in the mass, which has previously been reported in cardiac hemangiomas and is also a common radiologic sign of hemangiomas elsewhere in the body [7].
Although our patient was asymptomatic, the concern for potential hemodynamic compromise due to its compression of the great cardiac vein led us to proceed with surgical excision.
|
References
|
|---|
- Burke A, Virmani R. Tumors of the heart and great vessels Atlas of tumor pathology, 3rd series, fasc 16. Washington, DC: Armed Forces Institute of Pathology; 1996.
- Abraham KP, Reddy V. Neoplasms metastatic to the heart: review of 3314 consecutive autopsies Am J Cardiovasc Pathol 1990;3:195-198.[Medline]
- Solum AM, Romero SC, Ledford S, Parker R, Madani MM, Coletta JM. Left atrial hemangioma presenting as cardiac tamponade Tex Heart Inst J 2007;34:126-127.[Medline]
- Soberman MS, Plauth WH, Winn KJ, Forest GC, Hatcher Jr. CR, Sink JD. Hemangioma of the right ventricle causing outflow tract obstruction J Thorac Cardiovasc Surg 1988;96:307-309.[Abstract]
- Tomasian A, Iv M, Lai C, Jalili M, Krishnam MS. Cardiac hemangioma: features on cardiovascular magnetic resonance J Cardiovasc Mag Res 2007;9:873-876.[Medline]
- Moniotte S, Geva T, Perez-Atayde A, Fulton DR, Pigula FA, Powell AJ. Images in cardiovascular medicine. Cardiac hemangioma. Circulation 2005;112:e103-e104.[Free Full Text]
- Kemp JL, Kessler RM, Raizada V, Williamson MR. Case report. MR and CT appearance of cardiac hemangioma. J Comput Assist Tomogr 1996;20:482-483.[Medline]
Top
Abstract
Introduction
