International Journal of Cardiology 176 (2014) e63–e65
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Left ventricular fibroma: What cardiac magnetic resonance imaging may add?☆ Matteo Gravina a, Grazia Casavecchia b, Antonio Totaro b, Riccardo Ieva b, Luca Macarini a, Matteo Di Biase b, Natale Daniele Brunetti b,⁎ a b
Radiology Department, University of Foggia, Italy Cardiology Department, University of Foggia, Italy
a r t i c l e
i n f o
Article history: Received 23 July 2014 Accepted 24 July 2014 Available online 4 August 2014 Keywords: Cardiac fibroma Cardiac tumor Cardiac magnetic resonance imaging Late gadolinium enhancement
Cardiac fibromas are benign connective tissue tumors derived from fibroblasts that occur predominantly in children and constitute the second most common type (after the rhabdomyoma) of primary cardiac tumor occurring in the pediatric age group [1]. Most are detected in children younger than 10 years, and about one-third are diagnosed in infants younger than 1 year. Males and females appear to be equally affected. Cardiac fibromas are typically large tumors ranging from 3 to 10 cm in diameter. They usually occur within the ventricular myocardium and much more frequently within the anterior free wall of the left ventricular wall or the inter-ventricular septum than in the posterior left ventricular wall or right ventricle [2]. Approximately 70% of fibromas are symptomatic, causing mechanical interference with intracardiac flow (usually with bulky intra-cavitary left ventricular or right ventricular tumors), ventricular systolic function (usually with large intra-myocardial left ventricular tumors), or conduction disturbances (usually with tumors arising in the inter-ventricular septum). The most common clinical manifestations are congestive heart failure (21%), ventricular tachy-arrhythmias (13%) and atypical chest pain (3.5%) [3]. Sudden cardiac death occurs in 14% of patients with fibromas, typically in infants. Cardiac fibromas do not show spontaneous regres-
☆ The institution(s) where work was performed: University of Foggia, Cardiology Department, Foggia, Italy and University of Foggia, Radiology Department, Foggia, Italy. ⁎ Corresponding author at: Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2014.07.072 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
sion and surgical resection generally remains the treatment of choice for these tumors in children. A 51-year old man (C.R.) was referred to the emergency room for typical dizziness, sweating and vomit. Electrocardiogram showed sinus rhythm with Q wave in D1, D2, aVL and from V4 to V6 with T wave inversion from V4 to V6. Blood pressure at admission was 150/100 mm Hg, troponin-I values were normal. The patient was therefore admitted to the acute cardiac care unit with a diagnosis of suspected acute coronary syndrome. Echocardiography showed, in off axis views, a heterogeneous oval mass of the left ventricular lateral wall (5 × 3 cm) without involvement of mitral valve apparatus (Fig. 1a–b). Coronary angiography was normal. Cardiac magnetic resonance imaging (cMRI), performed with a 1.5-T magnet (Philips Achieva) and a cardiac phased-array multi-coil, showed in the mid-apical left ventricular lateral wall and inferior-lateral wall segments a nodular intra-myocardial formation (5.3 × 3.6 cm) isointense in the sequences T1-TSE (turbo spin echo Fig. 2 left) and in CINE-TFE sequences (turbo field echo Fig. 2 right; Videos 1–3), hypointense in the sequences T2-SPIRR BB (black-blood — T2-short-tau-inversion recovery Fig. 3a–b; Video 4). In the sequences for the dynamic study of first pass a minimal and inhomogeneous enhancement after gadolinium was evident (Fig. 4 left; Video 5). In late enhancement PSIR-TFE (phase sensitive inversion recovery turbo field echo) sequences, the nodular formation was hyper-intense (Fig. 5; Video 6). A diagnosis of cardiac fibroma was therefore based on such cMRI findings (iso-intense mass in cine “bright blood” balanced fast fieldecho images and in T1, hypo-intense in T2-STIR, minimal enhancement with gadolinium at the dynamic first pass and hyper-intense in PSIR sequences). The patient did not undergo endo-myocardial biopsy and surgical excision because of the large dimension of the mass. The cardiac fibroma is a rare benign tumor of the heart. The first tool to assess such lesion is echocardiography, which can provide information on the tumor's extent and on ventricular and valvular function. cMRI may improve and help the diagnosis by the tissue characterization of the lesion. cMRI allows the identification of cardiac and para-cardiac suspicious masses; a precise definition of the extension and the relationships as well as possible involvement of vascular and mediastinal structures, the infiltration of the pericardium and relationships with normal intra-cardiac structures may be obtained. Finally, the signal characteristics and contrast are useful for tissue characterization of
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M. Gravina et al. / International Journal of Cardiology 176 (2014) e63–e65
Fig. 1. a) Apical view echocardiograph without evidence of any ventricular mass. b) Off axis view echocardiograph showing an oval mass apparently located in left ventricular lateral wall.
lesion. The diagnosis of fibroma is suggested by the presence of a wellcircumscribed tumor with low-signal T1 and T2 images, and delayedcontrast hyper-enhancement [4]. cMRI also allows differential diagnosis with rhabdomyoma, thanks to hyper-intense in T2 images. Coronary
arteriography is helpful to assess the potential of arterial displacement or occlusion, when the fibroma is adjacent to the coronary arteries. cMRI clarifies tissue characteristics and information about tumor vascularity by contrast-enhanced studies; this accumulated diagnostic
Fig. 2. Cardiac magnetic resonance imaging showing showed in mid-apical left ventricular lateral wall and inferior-lateral wall segments a nodular intra-myocardial formation iso-intense in the sequences T1-TSE (turbo spin echo, left) and in CINE-TFE sequences (turbo field echo right).
Fig. 3. Cardiac magnetic resonance imaging: four chamber (a) and short axis (b) views T2-weighted images showing hypo-intense nodular mass in the mid-apical left ventricular lateral wall and inferior-lateral wall segments.
M. Gravina et al. / International Journal of Cardiology 176 (2014) e63–e65
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Fig. 4. Left: First pass: minimal enhancement with gadolinium. Right: Late enhancement in four-chamber views: the mass appear as hyper-intense.
Fig. 5. Cardiac magnetic resonance short axis imaging with late enhancement: Hyper-intense mass of diameter 5.3 × 3.6 cm.
information can better enable the practitioner to make a timely finding of cardiac fibroma.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.07.072.
References [1] Beghetti M, Gow RM, Haney I, Mawson J, Williams WG, Freedom RM. Pediatric primary benign cardiac tumors: a 15-year review. Am Heart J 1997;134:1107–14. [2] Burke AP, Rosado-de-Cristenson M, Virmani R. Cardiac fibroma: clinicopathologic correlates and surgical treatment. J Thorac Cardiovasc Surg 1994;108:862–70. [3] Parmely LF, Salley RK, Williams JP, Head III GB. The clinical spectrum of cardiac fibroma with diagnostic and surgical considerations: noninvasive imaging enhances management. Ann Thorac Surg 1988;45:455–65. [4] De Cobelli F, Esposito A, Mellone R, et al. Images in cardiovascular medicine. Late enhancement of a left ventricular cardiac fibroma assessed with gadolinium-enhanced cardiovascular magnetic resonance. Circulation 2005;112:e242–3.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Left ventricular fibroma: What cardiac magnetic resonance imaging may add?☆ Matteo Gravina a, Grazia Casavecchia b, Antonio Totaro b, Riccardo Ieva b, Luca Macarini a, Matteo Di Biase b, Natale Daniele Brunetti b,⁎ a b
Radiology Department, University of Foggia, Italy Cardiology Department, University of Foggia, Italy
a r t i c l e
i n f o
Article history: Received 23 July 2014 Accepted 24 July 2014 Available online 4 August 2014 Keywords: Cardiac fibroma Cardiac tumor Cardiac magnetic resonance imaging Late gadolinium enhancement
Cardiac fibromas are benign connective tissue tumors derived from fibroblasts that occur predominantly in children and constitute the second most common type (after the rhabdomyoma) of primary cardiac tumor occurring in the pediatric age group [1]. Most are detected in children younger than 10 years, and about one-third are diagnosed in infants younger than 1 year. Males and females appear to be equally affected. Cardiac fibromas are typically large tumors ranging from 3 to 10 cm in diameter. They usually occur within the ventricular myocardium and much more frequently within the anterior free wall of the left ventricular wall or the inter-ventricular septum than in the posterior left ventricular wall or right ventricle [2]. Approximately 70% of fibromas are symptomatic, causing mechanical interference with intracardiac flow (usually with bulky intra-cavitary left ventricular or right ventricular tumors), ventricular systolic function (usually with large intra-myocardial left ventricular tumors), or conduction disturbances (usually with tumors arising in the inter-ventricular septum). The most common clinical manifestations are congestive heart failure (21%), ventricular tachy-arrhythmias (13%) and atypical chest pain (3.5%) [3]. Sudden cardiac death occurs in 14% of patients with fibromas, typically in infants. Cardiac fibromas do not show spontaneous regres-
☆ The institution(s) where work was performed: University of Foggia, Cardiology Department, Foggia, Italy and University of Foggia, Radiology Department, Foggia, Italy. ⁎ Corresponding author at: Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424. E-mail address: [email protected] (N.D. Brunetti).
http://dx.doi.org/10.1016/j.ijcard.2014.07.072 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
sion and surgical resection generally remains the treatment of choice for these tumors in children. A 51-year old man (C.R.) was referred to the emergency room for typical dizziness, sweating and vomit. Electrocardiogram showed sinus rhythm with Q wave in D1, D2, aVL and from V4 to V6 with T wave inversion from V4 to V6. Blood pressure at admission was 150/100 mm Hg, troponin-I values were normal. The patient was therefore admitted to the acute cardiac care unit with a diagnosis of suspected acute coronary syndrome. Echocardiography showed, in off axis views, a heterogeneous oval mass of the left ventricular lateral wall (5 × 3 cm) without involvement of mitral valve apparatus (Fig. 1a–b). Coronary angiography was normal. Cardiac magnetic resonance imaging (cMRI), performed with a 1.5-T magnet (Philips Achieva) and a cardiac phased-array multi-coil, showed in the mid-apical left ventricular lateral wall and inferior-lateral wall segments a nodular intra-myocardial formation (5.3 × 3.6 cm) isointense in the sequences T1-TSE (turbo spin echo Fig. 2 left) and in CINE-TFE sequences (turbo field echo Fig. 2 right; Videos 1–3), hypointense in the sequences T2-SPIRR BB (black-blood — T2-short-tau-inversion recovery Fig. 3a–b; Video 4). In the sequences for the dynamic study of first pass a minimal and inhomogeneous enhancement after gadolinium was evident (Fig. 4 left; Video 5). In late enhancement PSIR-TFE (phase sensitive inversion recovery turbo field echo) sequences, the nodular formation was hyper-intense (Fig. 5; Video 6). A diagnosis of cardiac fibroma was therefore based on such cMRI findings (iso-intense mass in cine “bright blood” balanced fast fieldecho images and in T1, hypo-intense in T2-STIR, minimal enhancement with gadolinium at the dynamic first pass and hyper-intense in PSIR sequences). The patient did not undergo endo-myocardial biopsy and surgical excision because of the large dimension of the mass. The cardiac fibroma is a rare benign tumor of the heart. The first tool to assess such lesion is echocardiography, which can provide information on the tumor's extent and on ventricular and valvular function. cMRI may improve and help the diagnosis by the tissue characterization of the lesion. cMRI allows the identification of cardiac and para-cardiac suspicious masses; a precise definition of the extension and the relationships as well as possible involvement of vascular and mediastinal structures, the infiltration of the pericardium and relationships with normal intra-cardiac structures may be obtained. Finally, the signal characteristics and contrast are useful for tissue characterization of
e64
M. Gravina et al. / International Journal of Cardiology 176 (2014) e63–e65
Fig. 1. a) Apical view echocardiograph without evidence of any ventricular mass. b) Off axis view echocardiograph showing an oval mass apparently located in left ventricular lateral wall.
lesion. The diagnosis of fibroma is suggested by the presence of a wellcircumscribed tumor with low-signal T1 and T2 images, and delayedcontrast hyper-enhancement [4]. cMRI also allows differential diagnosis with rhabdomyoma, thanks to hyper-intense in T2 images. Coronary
arteriography is helpful to assess the potential of arterial displacement or occlusion, when the fibroma is adjacent to the coronary arteries. cMRI clarifies tissue characteristics and information about tumor vascularity by contrast-enhanced studies; this accumulated diagnostic
Fig. 2. Cardiac magnetic resonance imaging showing showed in mid-apical left ventricular lateral wall and inferior-lateral wall segments a nodular intra-myocardial formation iso-intense in the sequences T1-TSE (turbo spin echo, left) and in CINE-TFE sequences (turbo field echo right).
Fig. 3. Cardiac magnetic resonance imaging: four chamber (a) and short axis (b) views T2-weighted images showing hypo-intense nodular mass in the mid-apical left ventricular lateral wall and inferior-lateral wall segments.
M. Gravina et al. / International Journal of Cardiology 176 (2014) e63–e65
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Fig. 4. Left: First pass: minimal enhancement with gadolinium. Right: Late enhancement in four-chamber views: the mass appear as hyper-intense.
Fig. 5. Cardiac magnetic resonance short axis imaging with late enhancement: Hyper-intense mass of diameter 5.3 × 3.6 cm.
information can better enable the practitioner to make a timely finding of cardiac fibroma.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.07.072.
References [1] Beghetti M, Gow RM, Haney I, Mawson J, Williams WG, Freedom RM. Pediatric primary benign cardiac tumors: a 15-year review. Am Heart J 1997;134:1107–14. [2] Burke AP, Rosado-de-Cristenson M, Virmani R. Cardiac fibroma: clinicopathologic correlates and surgical treatment. J Thorac Cardiovasc Surg 1994;108:862–70. [3] Parmely LF, Salley RK, Williams JP, Head III GB. The clinical spectrum of cardiac fibroma with diagnostic and surgical considerations: noninvasive imaging enhances management. Ann Thorac Surg 1988;45:455–65. [4] De Cobelli F, Esposito A, Mellone R, et al. Images in cardiovascular medicine. Late enhancement of a left ventricular cardiac fibroma assessed with gadolinium-enhanced cardiovascular magnetic resonance. Circulation 2005;112:e242–3.
