Case presentation
A 26-year-old-man presented to the outpatient clinic of cardiac surgery
with a complaint of left hemithorax chest tightness and a cardiac mass
revealed by echocardiography. The onset of his symptoms was one year
before presentation when he developed slowly progressive left-hemithorax
chest heaviness and mild dyspnea. He did not report palpitation,
syncopal episodes, diaphoresis, lower limbs edema, or severe dyspnea. He
did not have a significant medical history or family history of
cardiovascular or pulmonary diseases. In his diagnostic investigations
prior to his presentation, electrocardiography (ECG) showed T wave
inversion in precordial leads of V3 to V6. To evaluate myocardial
ischemia, a myocardial perfusion scan was done which indicated moderate
ischemia of the apex, septum, and anterior wall but preserved left
ventricular ejection fraction and proper wall motion and thickness.
Transthoracic echocardiography indicated immobile non-homogeneous
lobulated mass in the right ventricle (RV) apex (Figure 1). According to
the aforementioned findings, he was referred to our cardiac surgery
unit. Upon physical examinations, he had normal heart sounds without
murmurs and other organs exams were unremarkable. To further
characterize the patient’s cardiac tumor, cardiovascular magnetic
resonance imaging (CMR) was advocated (Figure 2). It showed a round
intracavitary mass in the RV apex with well-defined borders and
attachment which was isointense in T1 weighted-sequence and hyperintense
in T2 weighted and STIR sequences. Additionally, after administration of
gadolinium and in the first-pass perfusion imaging, the mass showed avid
homogenous enhancement and on late post-contrast images, the mass
exhibited intense contrast uptake and gadolinium enhancement. Chest CT
scan and laboratory studies comprising complete blood count, coagulation
studies, metabolic and electrolytes panels were unremarkable. Given
these workup results particularly CMR which was in favor of a highly
vascular mass, the patient was diagnosed clinically and radiologically
with a benign cardiac tumor, probably hemangioma. The patient underwent
tumor resection (Figure 3) and was discharged 3 days postoperatively
without any complication. Histopathologic examination was performed
which was not in favor of hemangioma (Figure 4). Despite revealing
vascular tissue in hematoxylin and eosin staining, interspersing
fibrotic tissue was prominent which made the diagnosis of angiofibroma
more likely. To exclude other possible diagnoses like hamartoma,
immunohistochemical (lHC) staining with CD31 and desmin besides
trichrome staining was done which confirmed the diagnosis of cardiac
angiofibroma. Eventually, the patient’s symptoms markedly abated soon
after surgery and in his follow-up, he was doing well with no recurrence
of symptoms after 2 months of discharge.