991 a patient with inferior q waves and chest pain: when hoof beats are not horses

Abstract Background Cardiac masses are commonly classified as neoplastic (primary and secondary) or non-neoplastic (e.g., thrombus or vegetation). Cardiac tumors are rare, and primary tumors are even rarer, with an estimated autopsy prevalence of < 0.1%. Differentiating between these masses is of paramount importance as treatment options greatly differ. Case presentation A 46-year-old male patient, current smoker, with family history of CAD and new onset hyperlipidemia and hypertension, underwent electrocardiogram (ECG) screening for an episode of chest pain. His ECG showed sinus rhythm with Q waves in inferior leads. The laboratory tests did not reveal any abnormality. His transthoracic echocardiogram showed normal biventricular function, and a lobular mass of 30×20 mm, that seemed in continuity with the antero-lateral (A-L) papillary muscle. For the presence of multiple cardiovascular risk factor, the patient underwent diagnostic coronary angiography which showed normal coronary arteries. Differential diagnoses were: hypertrophic cardiomyopathy with isolated hypertrophy of the A-L papillary muscle and LV mass. Cardiac magnetic resonance (CMR) was performed and demonstrated a pedunculated mobile non-enhancing 30×18mm mass within the LV anterior apex, that in the systolic phase contracts close relationships with the A-L papillary muscle which appears dislocated. This encapsulated formation determined a mild systolic obliteration of the LV cavity at the mid-apical portion. T1 imaging with and without suppression of adipose tissue, were compatible with cardiac intraventricular lipoma. The case was discussed in a multi-disciplinary heart team, and in accordance with the cardiac surgeon the patient underwent conservative management and follow up with echocardiography at 6 months and CMR at 1 year. Discussion Cardiac lipomas are rare benign primary cardiac tumors. They are usually indolent, asymptomatic and incidentally-discovered. Symptoms such as dyspnea, syncope or palpitations can occur if the tumor grows and causes LV obstruction, LV dysfunction or invasion of the conduction system. Sudden cardiac death has been reported, but the true incidence is unknown given its rarity. The most common location for cardiac lipomas is the inter-atrial septum, followed by endocardium of RA and LV. CMR is the imaging modality of choice when available and lipomas have a homogeneous appearance of increased signal intensity on T1-weighted imaging, with a reduction in signal intensity in fat-saturated sequences. As the prevalence of cardiac lipomas is very low, there are no randomized clinical trials or large prospective cohorts to provide guidance for optimal treatment. Embolization or infiltration of the myocardium are not common. For large lesions causing obstruction, surgical resection is usually indicated. Conclusion Cardiac lipoma is a rare primary tumor of the heart. The comprehensive evaluation is highly dependent on multimodality imaging methods. The best treatment strategy is still not clear and should be individualized.