Ann Thorac Surg 2002;73:979-981
© 2002 The Society of Thoracic Surgeons
Case report
Left atrial cardiac hemangioma associated with shortness of breath and palpitations
Lucy J. Lo, MDa,
Ramsay C. Nucho, MDb,
John W. Allen, MDc,
Richard L. Rohde, MDa,b,c,1,
Francis Y.K. Lau, MD*c
a Department of Internal Medicine, Loma Linda University School of Medicine, White Memorial Medical Center, Los Angeles, California, USA
b Department of Surgery, Loma Linda University School of Medicine, White Memorial Medical Center, Los Angeles, California, USA
c Department of Cardiology, Loma Linda University School of Medicine, White Memorial Medical Center, Los Angeles, California, USA
Accepted for publication June 28, 2001.
* Address reprint requests to Dr Lau, Department of Cardiology, White Memorial Medical Center, Suite 1231, 1720 Cesar E. Chavez Ave, Los Angeles, CA 90033, USA
e-mail: fyklaumd{at}pacbell.net
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Abstract
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We present a patient with a left atrial hemangioma associated with shortness of breath and irregular heartbeats. Imaging modalities used to evaluate this rare tumor demonstrated characteristic features of its vascular nature. After successful surgical excision of the tumor under cardiopulmonary bypass, there were no clinical or echocardiographic evidence of recurrence at 18 months.
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Introduction
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Among primary tumors of the heart, cardiac hemangiomas are extremely rare. The diagnosis of these benign tumors is aided by imaging techniques and coronary angiography, which detect their vascular nature. When associated with obstructive symptoms and compression of cardiac structures, the tumors may be treated by surgical excision under cardiopulmonary bypass. We describe the evaluation and successful resection of a large left atrial hemangioma.
A 50-year-old woman presented with complaints of dyspnea on exertion and episodes of irregular heartbeats over the past 6 months. Physical examination revealed normal heart sounds without murmurs. Initial studies included an electrocardiogram which showed sinus rhythm with normal axis and no conduction defects. Chest x-ray film revealed a double density along the right parasternal margin without pulmonary vascular redistribution or cardiomegaly. A transthoracic echocardiogram demonstrated a nonobstructive mass of minimal mobility situated posteriorly in the left atrium. In homogeneous enhancement on magnetic resonance imaging (Fig 1)
confirmed the presence of a large vascular mass occupying almost the entire left atrium with displacement of the interatrial septum towards the right. Cardiac catheterization revealed hemodynamically stable right and left heart pressures without any gradient across the mitral or aortic valves. Coronary arteriography (Fig 2)
demonstrated a blood supply to the mass from branches of the left circumflex and right coronary arteries, in addition to a tumor blush and vascular lakes.
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Fig 1. Axial T2-weighted magnetic resonance image through level of left atrium showing a high signal mass (arrows) occupying almost the entire left atrium and encroaching on the right atrium. (LV = left ventricle; RV = right ventricle.)
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Fig 2. Coronary angiography in right anterior oblique view demonstrating the vascular supply of the tumor from the left circumflex (A) and right coronary artery (B). Vascular lakes are also seen within the tumor (arrows).
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Through a median sternotomy approach, the left atrium was explored on cardiopulmonary bypass. The mass was noted to be growing within the left atrial free wall into the pericardial sac and compressing the left atrial chamber leaving the endocardium intact. An encapsulated mass (Fig 3)
of soft, spongy consistency measuring 8 x 5 x 4 cm was successfully removed from its attachment to the left atrial wall. Microscopic section (Fig 4)
of the specimen revealed irregular, large dilated spaces lined by endothelium consistent with a cavernous hemangioma. There were no postoperative complications. At 18 months follow-up, the patient was completely asymptomatic without arrhythmias or any evidence of tumor recurrence by two-dimensional echocardiography.
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Fig 4. Histologic section showing large dilated vascular spaces lined by bland endothelial cells and separated by loose stroma (hematoxylin and eosin, x400).
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Comment
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Hemangiomas are benign vascular tumors usually found on the skin but can also involve internal abdominal organs and, occasionally, the brain. While primary cardiac tumors have an estimated incidence between 0.001% and 0.03% at autopsy, cardiac hemangiomas are extremely rare, accounting for 5% to 10% of benign cardiac tumors in surgical series [1]. Histologically, hemangiomas are classified as capillary, cavernous, or arteriovenous, often having combined features and containing fibrous tissue and fat. Hemangiomas may involve any part of the heart in the myocardium, endocardium, or the pericardium where they usually occur in the epicardial layer. Depending on their location, the tumors may result in compression of cardiac structures, outflow tract obstruction, pericardial effusions, congestive heart failure, coronary insufficiency, and occasionally sudden death. A recent review of 23 cases of cardiac hemangiomas reported the most frequent clinical presentation as dyspnea on exertion (43%) and less frequently as arrhythmias (17%), while a few patients were asymptomatic (8%) [2].
Due to the availability of new noninvasive imaging techniques, an increasing number of cardiac hemangiomas are diagnosed during life. These tumors have an unpredictable outcome and may involute, stop growing, or proliferate indefinitely [3]. Complete excision is considered curative and typically has resulted in resolution of symptoms. Incomplete resection or simple biopsy have been performed for unresectable cases of extensive tumor infiltration [4]. Spontaneous regression of an unresectable tumor over a 2-year period has been reported [5]. Periodic echocardiographic examinations may be performed to monitor for recurring hemangiomas after resection [6].
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Footnotes
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1 Doctor Rohde passed away on February 12, 2001. 
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References
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Tabry I.F., Nassar V.H., Rizk G., Touma A., Dagher I.K. Cavernous hemangioma of the heart: case report and review of the literature. J Thorac Cardiovasc Surg 1975;69:415-420.[Abstract]
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Scully R.E., Mark E.J., McNeely B.U. Case records of the Massachusetts General Hospital. Case 4-1983. N Engl J Med 1983;308:206-214.[Medline]
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Palmer T.E., Tresch D.D., Bonchek L.I. Spontaneous resolution of a large cavernous hemangioma of the heart. Am J Cardiol 1986;58:184-185.[Medline]
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Abad C., Campo E., Estruch R., et al. Cardiac hemangioma with papillary endothelial hyperplasia: report of a resected case and review of the literature. Ann Thorac Surg 1990;49:305-308.[Abstract]
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Abstract
Introduction
