Cardiac cavernous haemangioma: diagnosis and treatment

Cardiac haemangiomas are exceptionally rare with only a 1–2% incidence in all detected benign heart neoplasms. The resectability depends on the tumour’s location and extent of invasion in the cardiac structures. Patients with an unresectable tumour may have a poor prognosis because of ventricular tachycardia, sudden death and local progression. We are presenting the successful treatment of a 40-yearold woman with a cavernous haemangioma of the right atrium (RA). A 40-year-old female patient was admitted to our hospital with the diagnosis of a mass in the mediastinum noted during a medical check-up. The patient was asymptomatic. Chest X-ray showed a well-circumscribed shadow in the right para-cardiac field (Fig. 1a). Transthoracic echocardiography (TTE) revealed a mass near the RA and the right ventricule (RV) (Fig. 1b). The left ventricular ejection fraction (LVEF) was 65% with mild tricuspid valve (TV) regurgitation and the mass compressed the RA. Chest computed tomography (CT) showed a mass 5.1 × 5.2 × 8.8 cm in the pericardium and near the anterior wall of the RA and the anterior wall of the RV without invasion of the diaphragm (Fig. 1c). The presence of the RAmass was confirmed by cardiac magnetic resonance imaging (MRI) (Fig. 1d). The patient underwent open heart operation with standard sternotomy. Cardiopulmonary bypass (CPB) was established with bicaval cannulation, caval snaring and arterial return to the ascending aorta. After opening the pericardium, the tumour was located in the anterior wall of the RA along the right-anterior atriovenricular groove (Fig. 2a,b). When the heart had arrested with cold blood cardioplegia, the tumour was resected en bloc with anterior wall of the RA, the second and third part of the right coronary artery (RCA) because of invasion into this part of the coronary artery. The RCA was bypassed with the saphenous vein graft. The deficit of the anterior wall of the RA was closed with untreated fresh autologous pericardium with 4-0 Prolene suture. The patient could be weaned easily off bypass. Perioperative transoesophageal echocardiography indicated no TV regurgitation. Pathological examination revealed that a mass was a cavernous-type haemangioma. The post-operative course was uneventful and the patient was discharged home on post-operative day 5. At 2 months follow-up, the TTE echo showed no recurrence, LVEF was 60% with normal TV function without regurgitation. Haemangiomas are benign and non-malignant vascular lesions, and occasionally found in internal organs. Cardiac haemangioma may be located in the pericardium, endocardium or myocardium. Despite their vascular origin, haemangiomas do not metastasize or undergo malignant transformation. The symptoms depend on the location of the tumour and the resultant cardiac haemodynamic consequences. Manifestations of the symptomatic patients are arrhythmias, heart failure, embolic episodes, pericardial effusion, cardiac tamponade, myocardial ischaemia and sudden death. In our case, the patient was asymptomatic, but the TTE study showed that the RA and RV were compressed by the tumour. These findings in combination with the size and location of the mass were suggested possible haemodynamic consequence. Echocardiography is the imaging method typically used to identify a cardiac mass, but CT and MRI are superior to echocardiography for further characterizing cardiac haemangiomas. MRI is considered the diagnostic tool to differentiate between benign and malignant tumours. On MRI, haemangiomas are characterized as a region of increased signal intensity on T1-weighted images, compared with the myocardium, due to slow flowing blood. On the other hand, multi-