RT Journal Article
SR Electronic
T1 47-year-old female with an apical mass
JF Heart
JO Heart
FD BMJ Publishing Group Ltd and British Cardiovascular Society
SP 886
OP 886
DO 10.1136/heartjnl-2016-310854
VO 103
IS 11
A1 Jack Andrews
A1 Christopher CE Lang
A1 Marc Dweck
YR 2017
UL http://heart.bmj.com/content/103/11/886.abstract
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