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Cardiac hemangiomas are benign tumors with an unpredictable natural history. Surgical resection is the treatment of choice; however, conservative management can be an alternative in some patients.

We report a case of a left-sided cardiac hemangioma that we managed conservatively for 11 years without obvious major complications in the patient, an adult woman.

Keywords: Diagnostic imaging/methods; heart neoplasms/diagnosis/therapy/ultrasonography; hemangioma/diagnosis/pathology/therapy/ultrasonography; treatment outcome; watchful waiting

Cardiac hemangioma is a rare, benign, primary cardiac neoplasm that consists of blood vessels. Symptoms depend on the tumor's location. The diagnosis can be made with use of echocardiography, computed tomography (CT), cardiac magnetic resonance (CMR), or combinations thereof. Diagnosis by means of biopsy is definitive. The treatment of choice is resection; however, we report here that long-term conservative management can be an alternative when surgical risk is high.

Case Report

In 2002, a 42-year-old Tunisian woman presented with chest pain and dyspnea. Her medical history was noncontributory. A precordial examination yielded nothing unusual. Chest radiographs showed cardiac enlargement and leftward bowing of the septum into the left ventricular (LV) cavity. An electrocardiogram (ECG) showed sinus rhythm, negative T waves in the inferior leads, and ST-segment depression in the apical and lateral leads. Transthoracic echocardiograms (TTE) and CT revealed a mobile vascular mass attached to the anterior and lateral LV wall and the wall of the left atrium, between the right pulmonary artery and the ascending aorta. The patient's LV ejection fraction was 0.60. There were no signs of compression of the adjacent structures. A coronary angiogram showed the mass and minor obstruction of the proximal left anterior descending coronary artery (LAD). During an exploratory thoracotomy, the mass bled profusely at the slightest touch. This made both resection and biopsy perilous, so neither was attempted.

In 2013, after 11 years of regular monitoring, the patient had worsening angina pectoris, but no signs of heart failure. We detected no complications. The ECG was unchanged. A TTE revealed tumor growth (Fig. 1). Coronary angiograms confirmed enlargement of the tumor and showed its obstruction of the left main coronary artery (LMCA) with retrograde filling of the LAD through collateral vessels from the right coronary artery (Fig. 2). The patient's LV function remained normal. On CT, the 70 × 60-mm tumor compressed the LMCA (Fig. 3). We treated the patient with higher doses of propranolol and nitrates. As of July 2015, the patient had stable angina.

Fig. 1. Transthoracic echocardiograms. The cardiac mass is seen attached to the left ventricular wall in A) 4-chamber and B) 2-chamber views. C) The mass is between the pulmonary artery trunk and the aorta (parasternal short-axis view). D) Color-flow Doppler mode reveals the vascular character of the mass.Fig. 1. Transthoracic echocardiograms. The cardiac mass is seen attached to the left ventricular wall in A) 4-chamber and B) 2-chamber views. C) The mass is between the pulmonary artery trunk and the aorta (parasternal short-axis view). D) Color-flow Doppler mode reveals the vascular character of the mass.Fig. 1. Transthoracic echocardiograms. The cardiac mass is seen attached to the left ventricular wall in A) 4-chamber and B) 2-chamber views. C) The mass is between the pulmonary artery trunk and the aorta (parasternal short-axis view). D) Color-flow Doppler mode reveals the vascular character of the mass.
Fig. 1. Transthoracic echocardiograms. The cardiac mass is seen attached to the left ventricular wall in A) 4-chamber and B) 2-chamber views. C) The mass is between the pulmonary artery trunk and the aorta (parasternal short-axis view). D) Color-flow Doppler mode reveals the vascular character of the mass.

Citation: Texas Heart Institute Journal 42, 5; 10.14503/THIJ-14-4121

Fig. 2. Coronary angiograms show obstruction of the left anterior descending coronary artery. Note A) late opacification of the vascular cardiac mass and B) retrograde filling of that artery through collateral vessels from the right coronary artery.Fig. 2. Coronary angiograms show obstruction of the left anterior descending coronary artery. Note A) late opacification of the vascular cardiac mass and B) retrograde filling of that artery through collateral vessels from the right coronary artery.Fig. 2. Coronary angiograms show obstruction of the left anterior descending coronary artery. Note A) late opacification of the vascular cardiac mass and B) retrograde filling of that artery through collateral vessels from the right coronary artery.
Fig. 2. Coronary angiograms show obstruction of the left anterior descending coronary artery. Note A) late opacification of the vascular cardiac mass and B) retrograde filling of that artery through collateral vessels from the right coronary artery.

Citation: Texas Heart Institute Journal 42, 5; 10.14503/THIJ-14-4121

Fig. 3. Computed tomograms show the cardiac mass between the pulmonary artery trunk and the aorta in A) transverse and B) coronal views. The tumor C) compresses the origin of the left main coronary artery and D) spares the left ventricular apex. / Ao = aorta; PA = pulmonary artery; Tm = tumorFig. 3. Computed tomograms show the cardiac mass between the pulmonary artery trunk and the aorta in A) transverse and B) coronal views. The tumor C) compresses the origin of the left main coronary artery and D) spares the left ventricular apex. / Ao = aorta; PA = pulmonary artery; Tm = tumorFig. 3. Computed tomograms show the cardiac mass between the pulmonary artery trunk and the aorta in A) transverse and B) coronal views. The tumor C) compresses the origin of the left main coronary artery and D) spares the left ventricular apex. / Ao = aorta; PA = pulmonary artery; Tm = tumor
Fig. 3. Computed tomograms show the cardiac mass between the pulmonary artery trunk and the aorta in A) transverse and B) coronal views. The tumor C) compresses the origin of the left main coronary artery and D) spares the left ventricular apex. Ao = aorta; PA = pulmonary artery; Tm = tumor

Citation: Texas Heart Institute Journal 42, 5; 10.14503/THIJ-14-4121

Discussion

Fewer than 100 cases of cardiac hemangioma have been reported.1 The tumor is most often found in the ventricles and the right atrium.2 Asymptomatic hemangiomas have been discovered on chest radiographs during evaluation of cardiomegaly or murmurs. In symptomatic patients, cardiac hemangiomas can cause arrhythmias, pericardial effusion, congestive heart failure, right ventricular outflow tract obstruction, coronary insufficiency, complete atrioventricular block, neurologic manifestations, and sudden death. Echocardiography is sensitive, noninvasive, and highly accurate in detecting cardiac tumors,3 including hemangioma. Coronary angiography and CMR are superior to echocardiography in qualitatively characterizing this tumor. As in our patient, angiograms usually reveal a blush that confirms the neoplasm's vascular nature. The results of CMR can show the hypervascularity of the hemangioma.

The natural history of cardiac hemangiomas is unpredictable: they can involute, stop growing, or proliferate indefinitely. In the presence of symptoms and diagnostic uncertainty about the nature of the lesion, the treatment of choice is surgical resection. Of 75 cardiac hemangiomas discussed in one review, at least 37 were resected; of these, only 30 were excised completely.4 Tumor recurrence has been documented after excision, so regular monitoring is recommended. Conservative management has been reported,5 as has a case similar to ours of LMCA occlusion secondary to LV hemangioma.6 We think that our 11-year experience is a reminder that conservative management can be an option in treating cardiac hemangiomas.

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Copyright: © 2015 by the Texas Heart® Institute, Houston
Fig. 1.
Fig. 1.

Transthoracic echocardiograms. The cardiac mass is seen attached to the left ventricular wall in A) 4-chamber and B) 2-chamber views. C) The mass is between the pulmonary artery trunk and the aorta (parasternal short-axis view). D) Color-flow Doppler mode reveals the vascular character of the mass.

Fig. 2.
Fig. 2.

Coronary angiograms show obstruction of the left anterior descending coronary artery. Note A) late opacification of the vascular cardiac mass and B) retrograde filling of that artery through collateral vessels from the right coronary artery.

Fig. 3.
Fig. 3.

Computed tomograms show the cardiac mass between the pulmonary artery trunk and the aorta in A) transverse and B) coronal views. The tumor C) compresses the origin of the left main coronary artery and D) spares the left ventricular apex.

Ao = aorta; PA = pulmonary artery; Tm = tumor

Contributor Notes

From: Department of Cardiology, Sahloul Hospital, 4054 Sousse, Tunisia

Address for reprints: Rym Gribaa, MD, Hôpital Sahloul, Route de la Ceinture, Hammam Sousse, 4054 Sousse, Tunisia, E-mail: rym_gribaa@yahoo.fr