Case Report: Incidentally diagnosed hemangioma of the right atrioventricular groove in an athlete

Patient information and initial presentation

A 31-year-old Caucasian female tennis player presented to the emergency department with dyspnea and dry cough for a few days. She had undergone surgery previously for a borderline ovarian tumor eight years ago. There was no history of cardiopulmonary disease, coronary artery disease, or other cardiovascular diseases. No abnormalities were found during the physical examination with no jugular venous distension.

Diagnostic assessment

A chest X-ray showed enlargement of the cardiac shadow suggestive of pericardial effusion (Figure 1). Transthoracic echocardiography confirmed a large circumferential pericardial effusion and showed a rounded, well defined pericardial hyperechoic lesion attached to the right atrioventricular groove. There was no right ventricular dysfunction.

Figure 1. Chest X-ray shows a globular enlargement of the cardiac shadow.

A thoracic computed tomography (CT) scan was performed, which showed a large pericardial effusion and confirmed a pericardial mass with homogenous contrast enhancement within the right atrioventricular groove (Figure 2).

Cardiac magnetic resonance imaging (MRI) confirmed the large pericardial effusion with a pedunculated ill-defined homogeneous hypointense mass on T1 and a hyperintense mass in the right atrioventricular groove with progressive enhancement after contrast administration on T2 (Figure 3).

Figure 2. Thoracic computed tomography (CT) scan with contrast: right atrioventricular groove mass with homogeneous enhancement (arrow).

Figure 3.

Cardiac MRI four-chamber view cine steady state free precession (A), black blood T1 weighted without (B) and after gadolinium administration (C): Rounded well defined homogenous hyperintense T2 hypointense T1 mass in right atrioventricular groove with homogenous enhancement after contrast administration (arrow). Note large pericardial effusion (star).

A coronary angiography was performed, which showed tumor blush.

Intervention

The patient was referred to a cardiovascular surgery center to be operated on by an experienced cardiac surgeon. General anaesthesia was performed in supine position. Anaesthesia induction was performed by intravenous bolus of propofol (2mg/Kg), tracrium (0.5 mg/Kg) and fentanyl (2 mcg/Kg). Anaesthesia maintenance was performed by isoflurane 1.5% in oxygen and continuous intravenous infusion of tracrium (0.01 mg/Kg/min) and fentanyl (1 mcg/kg/hour). Surgery was initiated by a median sternotomy. Initial examination showed no extension of the mass into the cardiac chamber. A safety total excision of the mass was done using cutting diathermy. Vascular, pericardial and sternal sutures were performed by polypropylene, vicryl and wire, respectively. The anatomopathological examination of the mass revealed conjunctive tumor proliferation, vascular differentiated and concluded with a diagnosis of cavernous hemangioma. Post-procedural medication included antibiotic therapy with cefazolin (1 g intravenously, twice a day) for 48 hours, preventive anticoagulation by low molecular weight heparin (Enoxaparin 0.4 ml subcutaneously, once a day) and analgesic therapy by paracetamol (1 g intravenously, three times a day). Post-operative course was favorable and the patient was discharged after 72 hours.

Follow-up

Two months after surgery, the patient developed progressive dyspnea vomiting and precordial chest pain. CT scan found loculated left pleural effusion. Chest physiotherapy (one session a day) for two weeks and paracetamol (1 g orally, twice a day) for one week were prescribed with a favorable outcome. The patient remains well after two years of follow-up.