European Journal of Echocardiography 2008 9(1):52-53; doi:10.1016/j.euje.2006.08.004
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2006. For permissions please email: journals.permissions@oxfordjournals.org.
Cardiac hemangioma of the right atrium
Silméia Garcia Zanati1,*,
João Carlos Hueb1,
Ana Lúcia Cogni1,
Maria Gorete Teixeira de Morais1,
Luiz Eduardo de Almeida Prado Franceschi2,
Maurício Morceli3,
Antonio Carlos Cicogna1 and
Beatriz Bojikian Matsubara1
1 Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), CEP18618-000, Botucatu, São Paulo, Brazil
2 Department of Pathology, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
3 Department of Radiology, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
Received 14 July 2006; accepted after revision 20 August 2006; online publish-ahead-of-print 10 October 2006.
* Corresponding author. Tel: +55 14 3882 2969; fax: +55 14 3882 2238. E-mail address: sgzanati{at}fmb.unesp.br
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Abstract
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Primary cardiac tumors are rare, with an incidence range between
0.001% and 0.030% at autopsy. Recent technical advances have
facilitated diagnosis and surgical treatment of such lesions.
Patients with a resectable tumor usually have a good prognosis,
but patients with an unresectable tumor may have a poor prognosis.
This report shows a case of right atrial hemangioma growing
like an extracardiac mass, with cardiac tamponade the only clinical
presentation.
Keywords: Cardiac tumor; Echocardiography; Heart failure
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Introduction
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Cardiac hemangiomas are exceptionally rare with only a 1–2%
incidence in all detected benign heart neoplasms.
1 Tumors with
extracardiac extension are rarely symptomatic and found by chance.
2 This report shows a case of right atrial hemangioma growing
like an extracardiac mass, with cardiac tamponade as the only
clinical presentation.
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Case report
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A white 30-year-old male was seen at the University Hospital
in January 2002 with cough and chest pain for the past 5 days.
At physical examination, it was found arterial blood pressure
of 100
x 80 mmHg, heart rate of 120 bpm, mild jugular ingurgitation,
and regular cardiac rhythm without murmurs.
Chest radiography showed increased heart size. Electrocardiogram showed a low voltage complex and sinusal rhythm. Transthoracic echodopplercardiogram revealed large pericardial effusion and signs of cardiac tamponade. Closed pericardiocentesis showed bloody effusion without neoplastic cells at cytopathological examination. Biochemical tests were normal. The patient was discharged after clinical improvement. Four months later, he was rehospitalized because of severe dyspnea and reported a 12 kg body weight loss. Echodopplercardiogram revealed a large mass filling the right atrium, right ventricle and pericardial space, restricting the ventricle filling (Figure 1A). A chest computed tomography (CT) showed a hypodense heterogeneous mass, measuring 13 x 11 x 12 cm, with outer lining well defined by the pericardium (Figure 1B).
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Figure 1 (A) Transthoracic four-chamber view echocardiograph of the hemangioma, (arrow). (B) Chest computed tomography showing the extensive area occupied by the tumor (arrow). RV, right ventricle; RA, right atrium.
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Surgical approach was unable to completely remove the tumor.
Histological exam showed a benign vascular neoplasia with hyalinized
stroma and deposits of hemosiderin, without architectural disarrangement,
being defined as a combination of cavernous and capillary types
(
Figure 2A and
B). Interferon therapy was initiated without
success. One month later, the patient had sudden cardiac death.
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Figure 2 (A) Histological aspect of the tissue (Hematoxylin and Eosin, magnification x100) showing the vascular aspect of the hemangioma. (B) Showing the cells with no signs of malignancy (magnification x400; arrows: hemosiderin deposits).
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Discussion
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Cardiac hemangiomas grow from the benign proliferation of endothelial
cells and may occur in any part of the heart, being more common
in the right heart chambers.
3–6 Histologically they are
classified into three types: tumors composed of multiple, dilated,
thin walled vessels (cavernous type), smaller capillary-like
vessels (capillary type), and dysplastic arteries and veins
(arteriovenous type). A combination of cavernous and capillary
types are more frequently reported.
7
Most cardiac hemangiomas are asymptomatic, discovered incidentally by echocardiography, CT, MRI or at autopsy.1,5 Symptomatic patients present arrhythmias, pericardial effusions, congestive heart failure, right ventricular outflow tract obstruction, embolic episodes, myocardial ischemia, and sudden death. Although echocardiography may provide the information needed for surgical treatment, cardiac catheterization and MRI are more precise for diagnosis.7
Differential diagnosis of mass lesions in the heart include thrombi, myxoma, lipoma, fibroma, cyst, and other malignant tumors such as angiosarcoma. The outcomes of cardiac hemangioma are unpredictable. Patients with an unresectable tumor may have a poor prognosis because of ventricular tachycardia, sudden death, local progression, or systemic dissemination of the malignant tumor.8
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References
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- Sata N, Moriyama Y, Hamada N, Horinouchi T, Miyahara K. Reccurent pericardial tamponade from atrial hemangioma. Ann Thorac Surg (2004) 78:1472–5.[Abstract/Free Full Text]
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- Abad C, Campo E, Estruch R, Condom E, Barruiso C, Tassies D, et al. Cardiac hemangioma with papillary endothelial hyperplasia: report of resected case and review of the literature. Ann Thorac Surg (1990) 49:305–8.[Abstract]
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- Tomizawa Y, Endo M, Nishida H, Kikuchi C, Koyanagi H. Reconstruction of the left ventricle in a patient with cardiac hemangioma at the apex. Ann Thorac Surg (2001) 71:2032–4.[Abstract/Free Full Text]
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Abstract
Introduction