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A 34-year-old man presented with palpitations, headaches, and a history of supraventricular arrhythmias. Transesophageal and transthoracic echocardiography and magnetic resonance imaging (Fig. 1) showed a large non-pedunculated mass in the inferoposterior and lateral walls of the left ventricle. Coronary angiography and left ventriculography showed normal coronary vessels and a large filling defect in the aforementioned walls of the left ventricle. The mass was supplied primarily by the circumflex coronary artery and partially by the right coronary artery (Fig. 2).
Under bicaval, normothermic cardiopulmonary bypass and crystalloid cardioplegic arrest, the patient underwent complete removal of a solid transmural tumor (4 × 6 × 4 cm). The tumor originated in the endocardium between the anterior and posterior papillary muscles of the mitral valve, and it extended through the myocardium to the epicardium. The marginal branches of the circumflex coronary artery were ligated during the excision. The cardiac defect, enormous for an otherwise normal ventricle, was closed primarily in 2 layers with Teflon felt pledgets, as in aneurysmal repair. The microscopic diagnosis was mural capillary hemangioma of the heart, with cavernous areas, and without evidence of malignancy (Figs. 3 and and44).
The patient's postoperative course was uneventful, with no compromise in ventricular or valvular function despite the tumor's proximity to the papillary muscles of the mitral valve. He was discharged from the hospital on the 6th postoperative day. Over the last 8 years, the patient has undergone serial follow-up echocardiography; the results have shown mitral sufficiency, satisfactory ventricular function, and no recurrence of the tumor.
Hemangiomas of the heart comprise 5% to 10% of benign cardiac tumors in surgical series1; fewer than 100 surgically discovered cases have been reported in the world literature. Histologically, hemangiomas are classified as cavernous, capillary, and arteriovenous.1 They are localized in the atria, the ventricles, the ventricular septum, the pericardium, and very rarely the mitral valve. They can reach a large size, and, in 75% of cases, they are mural. Although most hemangiomas are asymptomatic, they can present with arrhythmias, conduction disturbances, pericardial effusion, coronary insufficiency, outflow tract obstruction, or congestive heart failure. Sudden cardiac death, consequent to conduction disturbances or rupture and tamponade, has been reported.1,2 Echocardiography is a sensitive diagnostic method3,4 that can be supplemented by coronary angiography, ventriculography, and magnetic resonance imaging.5–7 The differential diagnosis is myxoma or hemangiosarcoma. When diagnosed, hemangiomas should be removed because of the possibility of rupture8,9 and tamponade.10 In most cases, as with our patient, excision is considered curative.
Address for reprints: Kyriakos St. Rammos, MD, 29 Karolou Diehl str., Thessaloniki 54623, Greece. E-mail: rg.tenhtrof.eht@sommar