Asian Cardiovasc Thorac Ann 2003;11:258-260
© 2003 Asia Publishing EXchange Ltd
Left Ventricular Fibroma Causing Atypical Chest Pain
Mukesh Goel, MCh,
Rajneesh Malhotra, MCh,
Vijay Kohli, MCh,
Manisha Mishra, MD,
Sudhir Jain, MD,
Yatin Mehta, MD,
Naresh Trehan, MD
Escorts Heart Institute and Research Centre, New Delhi, India
For reprint information contact: Rajneesh Malhotra, MCh Tel: 91 11 6825000/6825001 Fax: 91 11 6825013 email: rajneesh.malhotra{at}ehirc.com Escorts Heart Institute and Research Centre, Okhla Road, New Delhi 110025, India.
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ABSTRACT
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A 29-year-old man with atypical chest pain for 3 years and exertional angina for 3 months was found to have a large homogenous mass in the apicolateral area of the left ventricle. The mass, weighing 78 g, was excised successfully and identified as a fibroma.
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INTRODUCTION
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Ventricular fibroma is a rare tumor of the heart. Despite being histologically benign, it can prove fatal because of its size and location. Treatment consists of complete excision if possible, although long-term survival has been reported after debulking of large ventricular fibromas.1 A case of left ventricular fibroma treated surgically at our institute is described.
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CASE REPORT
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A 29-year-old man presented with atypical chest pain for 3 years and exertional angina for 3 months. Clinical examination and chest radiography were unremarkable. Electrocardiography revealed T-wave inversion in chest leads V4–V6. Echocardiography detected a large homogenous mass in the apicolateral area of the left ventricle. Magnetic resonance imaging (MRI) confirmed an ellipsoid circumscribed 66 x 54 x 31-mm mass in the apicolateral wall of the left ventricle, partially encroaching into the ventricular cavity (Figure 1
). The patient underwent surgery via a median sternotomy with cardiopulmonary bypass and cold cardioplegic arrest. There was a solid oval mass approximately 6 x 5 cm visualized on the apicolateral wall of the left ventricle (Figure 2). The mass was excised by a longitudinal incision in the left ventricular wall overlying the mass. The resultant defect in the ventricular wall was repaired with a double patch of pericardium supported with Dacron, and a second layer of residual atrophic ventricular wall over the patch. The patient was weaned off cardiopulmonary bypass without difficulty and his postoperative course was uneventful. The excised mass was oval, solid, grey-white, and smooth, weighing 78 g (Figure 3). Histology confirmed the diagnosis of fibroma (Figure 4). The patient was well 3 months after the surgery. Postoperative echocardiography showed mild redundancy of the anterior mitral leaflet. There was no regional wall motion abnormality, and the ejection fraction was normal.
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Figure 1. Magnetic resonance image showing an ellipsoid mass in the apicolateral wall of the left ventricle, partially encroaching into the ventricular cavity.
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Figure 4. Photomicrograph of tissue from the excised mass showing the characteristics of fibroma. Hematoxylin and eosin stain, original magnification x 160.
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DISCUSSION
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Primary cardiac fibromas are very rare. Reported cases have occurred in patients with ages ranging from newborn to elderly, and nearly 80% of cardiac fibromas occur in children and teenagers.3 Heredity and gender are irrelevant.3 A congenital origin of this tumor is probable and it is frequently identified without symptoms. The majority of fibromas are found in the intraventricular septum or the left ventricular free wall.3 Fibromas can present as a rhythm disorder leading to sudden death, as congestive heart failure, and rarely, as chest pain.4 Many are recognized during routine chest radiography or at postmortem examination.4 A fibroma may mimic valvular stenosis, coronary disease with ventricular aneurysm, and endocardial fibroelastosis.5 In one case, it presented as acute myocardial infarction.6 A variety of nonspecific abnormalities can be found on electrocardiography, including ventricular hypertrophy, rhythm or conduction disturbances, T-wave inversion in chest leads, and even ST-segment changes. Cardiomegaly with or without a focal bulge may be noted on a chest radiograph. Calcification is nonspecific. These tumors typically produce filling defects on left ventricular angiography. Although not a preferred investigation, angiography is helpful in showing coronary artery displacement. Echocardiography is the key diagnostic investigation to determine tumor location, the relationship to other cardiac structures, and hemodynamic effects. To evaluate resectability, echocardiography can be supplemented with thoracic scanning, MRI, and thallium-201 transaxial tomography.5 Assessment of the quantity and function of the uninvolved myocardium and analysis of mitral valve function are important to decide the potential resectability of a fibroma. In our patient, MRI clearly delineated the tumor and its relationship to the ventricular cavity and other structures.
The biologic behavior of these tumors is benign, however, they can cause sudden death due to malignant arrhythmias or outflow tract obstruction. The treatment is surgical excision. Complete resection should be attempted to avoid the possibility of recurrence.4 Excellent long-term results have been reported following complete resection.7 This may have to be followed by ventricular reconstruction including repair of an intraventricular septal defect and patch closure of a free wall defect, coronary artery bypass grafting, and valve repair or replacement.7 A very large tumor can be managed with partial excision to relieve cardiac symptoms. Good to excellent midterm results (4 years) have been reported following partial resection in infancy.1 Cardiac transplantation is a viable option in patients with large tumors that cannot be managed with complete or partial resection.2 Intraoperative echocardiography and videocardioscopy facilitate precise operative decisions and management of large cardiac tumors.8 These techniques provide assessment of the intraventricular cavity, subvalvular mitral apparatus, ventricular septum, and aortic outflow tract, obviating the need for a large ventriculotomy. Cardiac fibromas should be treated surgically as early as possible. Complete resection is the goal although sometimes only partial resection is possible. Cardiac transplantation should be considered for very large unresectable tumors.
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REFERENCES
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- Ceithaml EL, Midgley FM, Perry LW, Dullum MK. Intramural ventricular fibroma in infancy: survival after partial excision in 2 patients. Ann Thorac Surg 1990;50:471–2.[Abstract]
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- Burk AP, Virmani R. Atlas of tumor pathology: tumors of the heart and great vessels. 3rd series, fasc 6. Washington DC: Armed forces Institute of Pathology, 1996.
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- Dein JR, Frist WH, Stinson EB, Miller DC, Baldwin JC, Oyer PE, et al. Primary cardiac neoplasms: early and late results of surgical treatment in 42 patients. J Thorac Cardiovasc Surg 1987;93:501–11.
- Lee KA, Kirkpatrick JG, Moran JM, Pezzella AT. Left ventricular fibroma masquerading as postinfarction myocardial rupture. Ann Thorac Surg 1999;68:580–2.[Abstract/Free Full Text]
- Williams DB, Danielson GK, McGoon DC, Feldt RH, Edwards WD. Cardiac fibroma: long-term survival after excision. J Thorac Cardiovasc Surg 1982;84:230–6.[Abstract]
- Nease B, Conant P, Marath A, McKeown PP. Resection of left ventricular tumor using videocardioscopy and echocardiography. Ann Thorac Surg 1997;63:841–3.[Abstract/Free Full Text]
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ABSTRACT
Introduction
