Case Study

Giant right atrial lipoma mimicking tamponade

Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(3) 317–319 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313504938 aan.sagepub.com

Ahmadali Khalili1, Samad Ghaffari2, Ahmadreza Jodati1, Behrouz Shokoohi3 and Leili Pourafkari2

Abstract Cardiac lipomas are rarely encountered. They are mostly asymptomatic and may be discovered incidentally. We describe the case of a 56 year-old man with a presentation similar to tamponade. He had decreased heart sounds, global cardiomegaly, and oligemic lung fields. Echocardiography showed a 110  75-mm mass attached to the interatrial septum, almost completely occupying the right atrium. Chest computed tomography showed a large homogeneous low-attenuation mass with thin septa, originating from interatrial septum and filling the right atrium, consistent with lipoma. The patient underwent surgery for resection of the tumor. Pathologic examination was consistent with cardiac lipoma.

Keywords Cardiomegaly, heart atria, heart neoplasms, heart septum, lipoma

Introduction Primary tumors of the heart are rare. Nearly 75% of such tumors are benign, and the rest are malignant. Myxomas account for the majority of benign tumors, and the others are mostly lipomas, papillary fibroelastomas, and rhabdomyomas.1

Case report A 56-year-old previously healthy man presented at our emergency room with worsening dyspnea and increasing fatigue for the past 2 months. Past medical history was positive for hypertension treated with losartan 25 mg twice daily, but the medication had been stopped due to hypotension in the past few weeks. The patient was an occasional smoker. He did not report any chest pain, weight loss, or cough. On physical examination, he had plethora and appeared to be in respiratory distress. His blood pressure was 90/60 mm Hg and his heart rate was 105 beats per minute. His neck veins and the superficial veins on the chest were distended. Heart auscultation revealed a II/VI systolic murmur in the left sternal border and decreased heart sounds. The lungs were clear on auscultation, with decreased breath sounds bilaterally. The oxygen saturation was 91% in

room air. Routine laboratory tests were within normal limits. The erythrocyte sedimentation rate was 13 mmh 1 and C-reactive protein was negative. Electrocardiography showed atrial fibrillation with low voltage in the limb leads. Chest radiography showed global cardiomegaly with oligemic lung fields. Echocardiography was carried out with the clinical suspicion of pericardial effusion, which showed preserved function of the ventricles with biatrial enlargement and a very large immobile homogenous mass almost completely occupying the right atrium, restricting blood flow thorough the tricuspid valve (Figure 1). There was no pericardial effusion. Chest computed tomography with intravenous contrast showed a 1 Department of Cardiac Surgery, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2 Department of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 3 Pathology Department, Tabriz University of Medical Sciences, Tabriz, Iran

Corresponding author: Leili Pourafkari, MD, Cardiovascular Research Center Tabriz University of Medical Sciences, Tabriz, Iran. Email: [email protected]

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Figure 1. Four-chamber echocardiography image showing a large mass in right atirum.

110  75-mm homogeneous low-attenuation mass with thin septa, originating from the interatrial septum and filling the right atrium, suggesting a high likelihood of lipoma (Figure 2a and 2b). The patient underwent resection of the mass originating from interatrial septum, and the septum was repaired with a pericardial patch. On gross examination, the mass consisted of thinly encapsulated bright yellow fat, separated by fine fibrous trabeculae (Figure 3). Microscopic examination showed adipose tissue composed of mature fat cells (Figure 4). The postoperative course was uneventful and the patient was doing well at the 12-month follow-up visit.

Discussion Cardiac lipomas account for 10% of all cardiac tumors. They occur in all ages with an equal frequency in both sexes.2 Cardiac lipomas are usually asymptomatic and may be discovered incidentally during computed tomography or magnetic resonance imaging.3 They are well-encapsulated tumors, typically composed of mature fat cells.1 True cardiac lipomas are much less frequent than lipomatous hypertrophy of the interatrial septum, and occur in almost any location in the heart.1 The clinical manifestations of cardiac lipoma depend on the location of the tumor, and may vary from valvular dysfunction to obstruction of a cardiac chamber, impeding the filling and emptying processes. Those adjacent to valves present early with murmurs or valvular obstruction. Tumors of the right atrium, interatrial septum, and right ventricle can predispose to arrhythmias.4 In our case, the tumor occupied most of the right atrium, hindering flow through the tricuspid valve, and even protruded into the right ventricle, which led to a clinical picture similar to cardiac tamponade. Approximately 50% of these tumors have a subendocardial origin, 25% have an intramyocardial origin

Figure 2. (a, b) Chest computed tomography images with contrast, showing a 95  75-mm homogeneous low-attenuation mass with thin septa, originating from the interatrial septum and filling the right atrium.

Figure 3. Gross pathologic specimen of the tumor showing a mass consisting of thinly encapsulated bright yellow fat.

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Khalili et al.

319 underfilling of the right ventricle with rapid deterioration of symptoms at presentation, mimicking cardiac tamponade. Conflict of interest statement None declared

Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.

References Figure 4. Microscopic examination of the tumor showing adipose tissue composed of mature fat cells. The nuclei are fairly uniform without hyperchromasia. Cardiac muscle tissue is seen with marked hypertrophic changes.

(affecting most frequently the left ventricle, right atrium, and the interatrial septum), and the remaining 25% are of pericardial origin.5 In our patient, increased right atrial pressure and distension of the right atrium or the probable intramyocardial origin of the tumor could account for the atrial fibrillation. Indications for surgery of cardiac fatty lesions are intractable arrhythmias, valvular dysfunction, inflow or outflow obstruction, a thromboembolic event, and inability to confidently exclude liposarcoma.2 This case is unique because of the large size of the lipoma, which caused

1. Ganame J, Wright J and Bogaert J. Cardiac lipoma diagnosed by cardiac magnetic resonance imaging. Eur Heart J 2008; 29: 697. 2. Gulmez O, Pehlivanoglu S, Turkoz R, Demiralay E and Gumus B. Lipoma of the right atrium. J Clin Ultrasound 2009; 37: 185–188. 3. Salanitri JC and Pereles FS. Cardiac lipoma and lipomatous hypertrophy of the interatrial septum: cardiac magnetic resonance imaging findings. J Comput Assist Tomogr 2004; 28: 852–856. 4. Matta R, Neelakandhan KS and Sandhyamani S. Right atrial lipoma. Case report. J Cardiovasc Surg 1996; 37: 165–168. 5. da Silveira WL, Nery MW, Soares EC, Leite AF, Nazzetta H, Batista MA, de Oliveira CP and de Oliveira VG. Lipoma of the right atrium. Arq Bras Cardiol 2001; 77: 361–368.

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Giant right atrial lipoma mimicking tamponade.

Cardiac lipomas are rarely encountered. They are mostly asymptomatic and may be discovered incidentally. We describe the case of a 56 year-old man wit...
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