Cardiac hemangiomas are rare primary cardiac tumors, with an incidence of only 1–2% of all cardiac primary tumors. These tumors are classified based on their histologic appearance in three categories: cavernous, capillary, and arteriovenous. The cavernous type has small vessels in its border with multiple dilations, the capillary type has numerous small-vessels similar to capillaries, while the arteriovenous has dysplasia of the arteries and veins . This histological difference arises from hyperplasia or abnormal dilation of the small arterioles, venules, and capillaries . They can appear at any stage of life and cardiac chamber, however they are most commonly found in the atrium. Although the clinical manifestations are varied, depending on the age of the patient, chamber localization, size, and rate of growth, most symptomatic patients have hemodynamic repercussions from valve, coronary vessels, or electrical pathways changes. Complex cases can involve other organs due to extrinsic compression, such as esophageal, tracheal, or ventricular prolapse like in this case report, resulting in high embolization risk.
Complementary images are of diagnostic use only, given that the definite diagnosis is histopathologic. However, an echocardiogram, computed tomography (CT) scan, CT angiography, or cardiac magnetic resonance image (MRI) will provide precise details that can be used in the operative approach. Given our patient’s clinical presentation and the high embolic or sudden death mortality risk, an immediate surgical excision was required. As of 2018, reports of Jehovah’s Witness supporters are estimated to be approximately 8 million worldwide, which as is common knowledge can be difficult to treat due to their beliefs in cardiac interventions . However, in this case report a successful excision was completed without cardiac arrest with an on-pump beating-heart to minimize risks, achieving an excellent result with no reported complications short or long-term.
Previous reports of right chamber hemangiomas have recently been reported, however most have been of significant small sizes. Jiang et al. reported an excision of a right ventricular 68 × 50 × 26 mm mass without any hemodynamic repercussion . Additionally Iida et al. also reported a 28.2 × 22.8 mass located in the right ventricle surface , as did Samanidis et al. with a 51 × 52 × 88 mm mass located in the right atrium without extension to any other chambers . Lastly, Takahashi et al. did report a larger than usual hemangioma (60 × 60 mm) located in the left atrial appendage . The importance of this case report reveals the compromise compared to other large hemangiomas, given that in our case report the mass affected the right chambers of the heart due its large size and subsequently proved a high-risk situation for the patient.