PT  - JOURNAL ARTICLE
AU  - Jack Andrews
AU  - Christopher CE Lang
AU  - Marc Dweck
TI  - 47-year-old female with an apical mass
AID  - 10.1136/heartjnl-2016-310854
DP  - 2017 Jun 01
TA  - Heart
PG  - 886--886
VI  - 103
IP  - 11
4099  - http://heart.bmj.com/content/103/11/886.short
4100  - http://heart.bmj.com/content/103/11/886.full
SO  - Heart2017 Jun 01; 103
AB  - 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.Figure 1 (A) Preoperative cardiac MR (CMR) perfusion. (B) Preoperative late gadolinium enhancement. (C) Postoperative CMR perfusion. (D) Postoperative early gadolinium enhancement.supplementary figure[heartjnl-2016-310854supp_figure.pdf]supplementary video[heartjnl-2016-310854supp_videoA.mp4]supplementary video[heartjnl-2016-310854supp_videoB.mp4]supplementary video[heartjnl-2016-310854supp_videoC.mp4]supplementary video[heartjnl-2016-310854supp_videoD.mp4]supplementary video[heartjnl-2016-310854supp_videoE.mp4]Question What is the next most appropriate management step? Antibiotic therapy for pericardial abscessAnticoagulation for LV thrombusIntravenous fluids with close clinical and imaging follow-up of the intramyocardial haemorrhage and pericardial haematomaReturn to theatre for excision of residual tumourUrgent pericardiocentesis to drain pericardial collection