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Case Report

A rare case of a left atrial hemangioma mimicking a myxoma

Saikat Bandyopadhyay, Ratan Kumar Das1, Ashima Bhelotkar1, Tanmay Acharia1
Departments of Anesthesiology and Critical Care Medicine, 1Cardiothoracic and Vascular Surgery, Medica Superspecialty Hospital, Kolkata, India

ABSTRACT

A 68-year-old gentleman presented with a recent history of exertional dyspnea associated with anginal chest pain. Transthoracic echocardiography revealed a well-circumscribed mass in the left atrium attached to the inter-atrial septum. Aprovisional diagnosis of left atrial(LA) myxoma was made. Coronary angiography revealed significant singlevessel disease. The patient underwent coronary artery bypass grafting and resection of the LA tumor. The histopathological diagnosis of the tumor came out to be a cardiac hemangioma. Key words: Cardiac hemangioma, Left atrial tumor, Transesophageal echocardiography

Received: 17-10-12 Accepted: 15-12-12

INTRODUCTION Hemangioma of the heart, presenting as a primary cardiac tumor is extremely rare. It makes up less than 3% of all reported tumors[1,2] in contrast to the much more common myxomas or lipomas occurring in the heart. They can be pericardial, intramyocardial or subendocardial.[3] Very few cases of cardiac hemangiomas have been reported to be arising from the inter-atrial septum mimicking the classic presentation of a myxoma. They may occur at any age starting from infancy to late adulthood. Clinical presentation varies widely. Manifestations due to arrhythmias, congestive cardiac failure, pericardial effusion, and thrombo-embolic events may be the presenting symptoms.[4] Echocardiography, computed tomography, or magnetic resonance imaging in combination or as an isolated imaging modality can identify the mass but ultimate diagnosis is by histopathological examination.[5] Although an isolated incidence of spontaneous regression of cardiac hemangioma[6] has been reported in a singular case, the mainstay of treatment is surgical excision of the tumor. CASE REPORT A 68-year-old gentleman presented with

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a recent history of exertional dyspnoea associated with anginal chest pain for a month. On trans-thoracic echocardiography, a large left atrial(LA) mass was identified. Aprovisional diagnosis of an intracardiac myxoma was made and the patient was admitted for surgical excision of the tumor. He had no other significant co-morbidity apart from an episode of paroxysmal atrial fibrillation at admission, which settled down spontaneously during his stay in the hospital. He was hemodynamically stable and his laboratory investigations as well as the chest X-ray were within normal limits. Coronary angiography revealed an 80% ostial stenosis of the ramus intermedius vessel along with minor plaques observed in the right coronary artery. Additionally, a large tortuous abnormal feeder vessel supplying the LA tumor was seen arising from the right coronary artery[Figure1]. The surgical plan was modified to coronary artery bypass grafting along with excision of the LA myxoma. After an uneventful induction of anesthesia, transesophageal echocardiography(TEE) was done. The TEE findings revealed a 4.75 4.45cm well-circumscribed mass arising from the interatrial septum [Figure 2]. After median sternotomy and heparinization, the patient was put on cardiopulmonary

Address for correspondence: Dr.Saikat Bandyopadhyay, D 401Mayfair Greens, 449 S. N. Ghosh Avenue, Narendrapur, Kolkata - 700103, West Bengal, India. E-mail:drsakiban@gmail.com.

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bypass(CPB) using aortic and selective bi-caval cannulation technique. Core cooling ensued, aorta cross-clamped, and root cardioplegia was given to achieve diastolic arrest of the heart. The right atrium(RA) was opened obliquely. As the base of the tumor could not be made out from the RA, the LA was opened through the inter-atrial groove. The tumor was found attached to the inter-atrial septum and roof of the LA, as was observed on TEE. The tumor was resected in toto with adjoining inter-atrial septum and roof of the LA. LA roof was repaired by direct closure. Pericardial patch closure of the inter-atrial septum was done using a 5-0 prolene suture. Rewarming started and the RA was closed in two layers using 5-0 prolene. The patient received a reverse saphenous venous graft to the ramus intermedius vessel. Thereafter, the heart was de-aired and the aortic cross clamp was removed. The heart spontaneously picked in sinus rhythm. After

rewarming to 37C, the patient was separated from CPB with a minimal inotropic support. Anticoagulation was reversed with protamine and the chest was closed after ensuring hemostasis. The TEE evaluation at the end of surgery showed complete excision of the LA mass and no leak through the repaired inter-atrial septum. The patient had an uneventful post-operative recovery and was discharged from hospital on the 7thpost-operative day. Three months following the surgery, the patient remains healthy with no further evidence of recurrence of the tumor. The excised tumor appeared as an encapsulated spherical mass measuring approximately 54cm. The cut section of the tumor revealed a uniformly spongy texture found to be filled with blood[Figure3]. The subsequent histopathological examination revealed it to be a cavernous hemangioma[Figure4]. The tumor was

Figure 1: Angiogram shows the origin of an abnormal feeder arising from the right coronary artery supplying the left atrial tumor

Figure 2: Transesophageal echocardiogram showing a well-circumscribed large tumor in the LA cavity in the mid-esophageal 2chamber view

Figure 3: The cut section of the tumor showing uniformly spongy vascular texture filled with blood

Figure 4: The histopathological section of the tumor revealed it to be a cavernous hemangioma. The tumor was shown to be composed of vessels of different caliber, majority of which were enlarged/dilated and filled with blood

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shown to be composed of vessels of different caliber, majority of which were enlarged/dilated and filled with blood. The vessels were anastomosed to each other and connected irregularly. DISCUSSION Primary cardiac hemangiomas are infrequent and benign neoplasms. Long-term prognosis of cardiac hemangioma is favorable. However, recurrence following surgical excision has been documented in clinical reports. [7] Occurrence of hemangiomas exclusively in LA is very unusual and has been reported only by few authors.[1,3,8-11] The natural history of cardiac angiomas is unpredictable. While some of these tumors remain asymptomatic and only discovered incidentally during surgery or upon autopsy, others may present with symptoms as a consequence of evolution of the tumor in the form of compression, infiltration, rupture, bleeding, embolization, growth or infection. Interestingly, a large tumor with abundant vascularity, as the atrial hemangioma in our case, and as also previously reported in cases of atrial myxomas, can also present with exertional dyspnoea and anginal chest pain, in spite of absence of significant coronary artery disease. Aprobable explanation of such pain is coronary steal phenomenon[12] owing to blood being drawn by the vessel feeding the tumor, away from a major coronary artery. However, our patient also had co-existing significant coronary artery disease of the ramus intermedius as a result of which it was not possible to ascertain whether the patients symptoms were due to coronary artery disease alone or because of the coronary steal effect of the hemangioma. Hemangiomas, being a vascular tumor, are clearly delineated on angiography; however, even myxoma also show increased vascularity on angiography[13] and as such, it is impossible for angiographic imaging alone to differentiate between the two. Although spontaneous regression has been

reported in hemangiomas, the incidence of such regression is far too low to leave alone a fairly large tumor suspicious of being a hemangioma, which may have been the cause of exertional dyspnoea and/or chest pain. As a result, the mainstay of treatment of these tumors is surgical resection. REFERENCES
1. MatsumotoY, WatanabeG, EndoM, SasakiH. Surgical treatment of a cavernous hemangioma of the left atrial roof. Eur J Cardiothorac Surg 2001;20:633-5. 2. SerriK, SchraubP, LafitteS, RoudautR. Cardiac hemangioma presenting as atypical chest pain. Eur J Echocardiogr 2007;8:17-8. 3. AbadC, de VaronaS, LimeresMA, MoralesJ, MarreroJ. Resection of a left atrial hemangioma. Report of a case and overview of the literature on resected cardiac hemangiomas. Tex Heart Inst J 2008;35:69-72. 4. PigatoJB, SubramanianVA, McCabaJC. Cardiac hemangioma. Acase report and discussion. Tex Heart Inst J 1998;25:83-5. 5. KojimaS, SumiyoshiM, SuwaS, TamuraH, SasakiA, KojimaT, etal. Cardiac hemangioma: Areport of two cases and review of the literature. Heart Vessels 2003;18:153-6. 6. PalmerTE, TreschDD, BonchekLI. Spontaneous resolution of a large, cavernous hemangioma of the heart. Am J Cardiol 1986;58:184-5. 7. ColliA, BudillonAM, DeCiccoG, AgostinelliA, NicoliniF, TzialtasD, etal . Recurrence of a right ventricular hemangioma. JThorac Cardiovasc Surg 2003;126:881-3. 8. LoLJ, NuchoRC, AllenJW, RohdeRL, LauFY. Left atrial cardiac hemangioma associated with shortness of breath and palpitations. Ann Thorac Surg 2002;73:979-81. 9. SataN, MoriyamaY, HamadaN, HorinouchiT, MiyaharaK. Recurrent pericardial tamponade from atrial hemangioma. Ann Thorac Surg 2004;78:1472-5. 10. SolumAM, RomeroSC, LedfordS, ParkerR, MadaniMM, ColettaJM. Left atrial hemangioma presenting as cardiac tamponade. Tex Heart Inst J 2007;34:126-7. 11. LisyM, BeierleinW, Mller H, Bltmann B, ZiemerG. Left atrial epithelioid hemangioendothelioma. JThorac Cardiovasc Surg 2007;133:803-4. 12. AlexiouK, WilbringM, MatschkeK. Angina pectoris as first manifestation of a huge biatrial myxoma. Acta Cardiol 2009;64:667-8. 13. AcikelS, AksoyMM, KilicH, KarapinarK, OguzAS, AydinH, etal. Cystic and hemorrhagic giant left atrial myxoma in a patient presenting with exertional angina and dyspnea. Cardiovasc Pathol 2012;21:e15-8.

Cite this article as: Bandyopadhyay S, Das RK, Bhelotkar A, Acharia T. A rare case of a left atrial hemangioma mimicking a myxoma. Ann Card Anaesth 2013;16:144-6. Source of Support: Nil, Conflict of Interest: None declared.

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