Intramural hemangioma of the left ventricle: accurate noninvasive diagnosis and surgical treatment.

A 38-year-old man was admitted to the hospital because of bronchitis and self-limited hemoptysis. He was heterozygous for factor V Leiden and had hyperhomocysteinemia. A thoracic computed tomographic (CT) scan, to screen for pulmonary emboli, instead revealed a 20-mm-diameter mass in the left ventricular myocardium. A CT angiogram showed that the mass was fed by a marginal branch of the left circumflex coronary artery and had no well-defined capsule (Fig. 1). A coronary angiogram showed a marginal branch that ended in a rounded stain or “tumor blush,” a typical sign of benign vascular tumors (Fig. 2). On cardiac magnetic resonance images, the T2-weighted signal was hyperintense (Fig. 3A), whereas the T1-weighted signal was isointense (Fig. 3B). When gadolinium contrast medium was administered, rapid enhancement during first-pass infusion and late homogeneous enhancement of the lesion indicated its vascular nature (Fig. 3C). Fig. 1. Computed tomographic coronary angiogram (3-dimensional reconstruction) shows that a marginal branch of the left circumflex coronary artery ends in the tumor (encircled), which is in the inferolateral wall of the left ventricle. Fig. 2. Coronary angiogram shows tumor blush (arrow). Fig. 3. Cardiac magnetic resonance images. A) The T2-weighted fast-spin echo sequence shows that the tumor has higher signal intensity than does the myocardium. B) The T1-weighted fast-spin echo sequence shows an isointense signal in comparison with the surrounding ... We concluded that the patient had a benign intramural hemangioma of the left ventricle, with no apparent complications. After a risk–benefit analysis, we surgically exposed the tumor (Fig. 4), carefully resected it, ligated its small nutritional vessels, and closed the defect with use of interrupted sutures. The patient recovered uneventfully. Fig. 4. Intraoperative photograph shows the exposed mass upon its removal. Macroscopic examination revealed a solid mass that had a smooth, bright, whitish surface of fibrous appearance and areas of muscle (Fig. 5A). Microscopic sections revealed a benign tumor with irregular capillary vascular structures and some cavernous patterns (Fig. 5B). There was no atypical proliferation of endothelial cells. Compressed myocardial fibers were found in the tumor's periphery. Immunohistochemical analysis confirmed the vascular nature of the cells. The final diagnosis was benign myocardial hemangioma. Fig. 5. A) Photograph shows a solid, fibrous tumor with surrounding cardiac muscle. B) Photomicrograph shows irregular capillary and cavernous patterns, lined endothelium, and a collagenous matrix (H & E, orig. ×100).