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.