Pericardial hemangioma vascularized via left anterior descending

Abstract

A 58-year-old female was suffering from recurrent pericardial effusion requiring repeated pericardiocentesis for 3 years. In all aspirations the effusion was clear without any signs of hemorrhage. Testing for adenosine desaminase, interferon gamma and PCR to determine the presence of DNA of Mycobacterium tuberculosis was negative. There is no history of acute pericarditis. Since 1999 she had recurrent deep venous thrombosis (DVT) with pulmonary embolism. For secondary prevention after pulmonary embolism she received low-dose heparin subcutaneously twice daily instead of oral anticoagulation, because of a tendency to fall. The patient reports a history of a dendroglioma, which was diagnosed in 1999 and treated with radiation. The patient had several cardiovascular risk factors like insulin-dependent diabetes mellitus, hyperlipoproteinemia and obesity. On review of family history, the patient denied any history of cardiac disease, congestive heart failure, arrhythmias or sudden death. On admission, she complained of progressive dyspnea NYHA class III and recurrent dizziness since the last pericardiocentesis, 4 weeks ago. She negated typical angina pectoris. An examination of the heart, lung, abdomen, and extremities disclosed no abnormalities. Neurologic examination was normal with no evidence of deficit. Transthoracic echocardiogram was performed displaying normal left ventricular function, preserved ejection fraction ([50%) and pericardial effusion of 13 mm in front of left atrium (LA) with signs of compression. Levels of serum electrolytes, cardiac and liver enzymes, renal function were all within normal ranges, as well as red and white blood cells and thrombocytes. Because of beginning pericardial tamponade pericardial puncture was performed once more with the aspiration of 600 ml of ensanguined pericardial fluid. In addition to previously performed laboratory diagnostic testing for rheumatic disease, especially lupus erythematosus was performed with negative findings for antibodies to antinuclear antibody, as well as anti-dsDNA, anti-Sm and antiphospholipid antibodies. The chest CT demonstrated a pericardial bleeding directly next to the visceral pericardium close to the origin of the pulmonary artery. For further clarification, cardiac MR imaging was performed yielding suspicion of a pericardial venous aneurysm because of a contrasting tumor in the venous phase (Fig. 1a). Because of ongoing bleeding with progression of pericardial effusion, the patient was referred to cardiac surgery for pericardiectomy. A preoperative coronary angiography could exclude coronary artery disease, but revealed a fistula between the proximal LAD and a vascularized structure (Fig. 1b). Surgical pericardiectomy was performed through a conventional sternotomy. A cherry-pit-sized tumor located in epicardial adipose tissue next to the pulmonary artery was located and extracted. Histopathological investigation confirmed the diagnosis of a pericardial hemangioma (Fig. 2a, b). Immunohistology revealed a small capillary hemangioma without any signs of malignancy (positive reactions C. Liebetrau (&) H. Mollmann H. Nef C. Hamm M. Weber Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 60231 Bad Nauheim, Germany e-mail: C.Liebetrau@Kerckhoff-Klinik.de