The management dilemma of a large left ventricular fibroma

Abstract

Background: Cardiac fibromas are rare, benign primary cardiac tumours predominantly observed in paediatric populations, with their occurrence in adults being exceptionally uncommon.

Case summary: We present the case of a 40-year-old physically active male with an incidentally discovered, large left ventricular fibroma during investigation for presumed ischaemic heart disease. Multimodal imaging, including computed tomography (CT) coronary angiography, transthoracic echocardiography, cardiac magnetic resonance imaging, and positron emission tomography-CT, revealed a 42 × 30 × 58 mm myocardial mass with significant calcification and myocardial invasion, ultimately diagnosed as a fibroma via biopsy. Given the patient's asymptomatic status, frequent ventricular ectopics, and high surgical risk associated with resection, a conservative management strategy was adopted. This included regular Holter monitoring and echocardiography to assess for arrhythmias, tumour progression, or functional compromise. The case underscores the limited evidence available for managing cardiac fibromas in adults, necessitating extrapolation from paediatric data and an individualized, patient-centred approach.

Discussion: This report highlights the challenges of decision-making in adult cardiac fibromas, particularly regarding arrhythmogenic potential and surgical considerations, and emphasizes the need for further studies to establish evidence-based guidelines for this rare condition.

Keywords: CT; Case report; Echocardiography; Fibroma; MRI; Multimodality imaging; Tumour.

Figure 1

Twelve-lead electrocardiograph on initial presentation, showing sinus rhythm with T wave inversion in inferior and lateral leads.

Figure 2

Computed tomography coronary angiogram, axial images displaying a 42 × 30 × 58 mm cardiac mass (A). (B) The complexity of the lesion with areas of calcification (blue arrow) and demonstrating the difficulty delineating whether arising from pericardium or myocardium.

Figure 3

Transthoracic echocardiogram images. A flipped apical four-chamber view (A) demonstrating a 3.02 cm by 4.5 cm well-circumscribed mass within the apical pericardium. (B) An apical two-chamber view with a mass of 4.52 cm × 3.37 cm.

Figure 4

Cardiac magnetic resonance imaging demonstrating the morphological and tissue characteristics of the left ventricular mass. Axial (A and B) and coronal (C) late gadolinium enhancement images show a well-circumscribed intramyocardial mass with intense, homogeneous delayed enhancement (blue arrows). T1-weighted (D and E) images show the lesion as isointense to mildly hypointense relative to normal myocardium, while T2-weighted short tau inversion recovery imaging (F) demonstrates low T2 signal intensity, consistent with dense fibrous tissue. First-pass perfusion sequences (G: axial; H: sagittal) show absent enhancement within the mass, confirming its avascular nature. The overall pattern of low T2 signal, homogeneous intense late gadolinium enhancement, and absent first-pass perfusion is characteristic of a cardiac fibroma, distinguishing it from other cardiac tumours such as myxoma, rhabdomyoma, or sarcoma.

Figure 5

(A) Fluorodeoxyglucose F-18 positron emission tomography (PET), coronal view showing physiological distribution of fluorodeoxyglucose F-18. (B) Positron emission tomography-computed tomography axial view demonstrating moderate uptake localizing to a normal papillary muscle (presumed physiological). (C) No evidence of pathological uptake throughout the myocardial mass (blue arrow).