Article Text
Abstract
Clinical introduction A 47-year-old female with no medical history presented with a sudden collapse. Physical examination, chest X-ray and high-sensitivity cardiac troponin I were normal, however ECG demonstrated anterior T-wave inversion. CT pulmonary angiography was performed which ruled out pulmonary embolism but revealed a non-calcified, homogenous mass at the left ventricular (LV) apex. It was not clear whether this mass was intramyocardial or pericardial. Transthoracic echocardiography confirmed the apical mass but was unable to establish its aetiology. Subsequent cardiac MR (CMR) demonstrated a highly vascular intramyocardial mass on perfusion imaging (Figure 1A, online supplementary video A), with striking, homogenous late gadolinium enhancement (Figure 1B) consistent with a diagnosis of cardiac fibroma.1 The patient underwent successful surgical excision of the mass (see online supplementary image A) and made a good symptomatic recovery, quickly mobilising around the ward. On examination, the patient was afebrile but had a blood pressure of 90/40 mm Hg and raised venous pressure. Postoperative imaging with echocardiography (see online supplementary video B) and CMR (Figure 1C, D and online supplementary video C) revealed some unexpected findings. Study the provided images.
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Question What is the next most appropriate management step?
Antibiotic therapy for pericardial abscess
Anticoagulation for LV thrombus
Intravenous fluids with close clinical and imaging follow-up of the intramyocardial haemorrhage and pericardial haematoma
Return to theatre for excision of residual tumour
Urgent pericardiocentesis to drain pericardial collection
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Footnotes
Collaborators David Northridge, Alan Japp, Vincenzo Giordano, David Dorward, David Newby.
Contributors JA planned, managed and wrote the report with guidance from CCEL and MD.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.