Prenatal Sonographic Diagnosis Of Cardiac Hemangioma With Postnatal Spontaneous Regression

Abstract

A 23-year-old pregnant woman, gravida 1 para 0, underwent ultrasound examination at 31 weeks' gestation on account of antepartum hemorrhage. Ultrasound revealed normal fetal biometry, no placenta previa and normal amniotic fluid volume. On fetal echocardiography there was a slightly increased cardiothoracic ratio (0.6) and a slight left-axis deviation and pericardial effusion on the four-chamber view. In addition, there was an intracardiac echogenic mass 15 × 17 × 20 mm in diameter protruding from the left ventricular wall (Figure 1) near the apex. The vascular nature of the mass was demonstrable with color power angiography and the main feeding vessel was clearly visualized (Figure 2). Minimal ascites was observed. Other structures were normal. Cardiac hemangioma was prenatally diagnosed. On the follow-up scans at 33, 35 and 37 weeks' gestation the cardiac size, pericardial effusion and ascites had not worsened but remained the same. Induction of labor was initiated at 37 weeks' gestation and a healthy male fetus weighing 2770 g was delivered vaginally. Postnatal echocardiography demonstrated the tumor mass in the left ventricle arising from the pericardium with typical internal blood flow signals on color flow mapping. The main feeding vessels were clearly demonstrated. The heart was slightly enlarged. Magnetic resonance imaging (MRI) revealed the typical characteristics of a hemangioma. Ascites and pericardial effusion disappeared shortly after birth. The mass was scheduled to be removed later. However, at the age of 3 months the baby was still healthy without any signs of cardiac decompensation and the mass was smaller when compared with the cardiac size. On follow-up serial echocardiograms the tumor gradually regressed and completely disappeared at about 6 months of age. Fetal echocardiographic four-chamber view reveals an intracardiac mass in the left ventricle. IVS, interventricular septum; PE, pericardial effusion; Sp, spine. Color power angiography of the intracardiac mass demonstrates feeding vessels in the tumor. Cardiac tumors are rare; the prevalence, reported from autopsy studies of patients of all ages, varies from 0.0017% to 0.28%1. Rhabdomyoma is the most common benign fetal cardiac neoplasm, whereas hemangioma is extremely rare, occurring at a frequency of only 1 in 19 cardiac tumors1. Fetal cardiac hemangioma usually arises from the atrial wall or pericardium. Although several case reports of cardiac tumors have been published, very few cases of cardiac hemangioma have been diagnosed prenatally. Though benign in nature, cardiac hemangioma can obstruct inflow or outflow from the heart, leading to cardiac arrhythmia, cardiac decompensation or even hydrops fetalis. A tumor may interfere with blood flow through the heart by extrinsic compression or intracavitary obstruction and can be associated with hypoplasia of the obstructed vessel or chamber. The newborn can also present with an asymptomatic murmur and the tumor is subsequently diagnosed by echocardiography. In previous reports the prenatal diagnosis of hemangioma was suspected but could not be definitively made due to the absence of flow signals. However, in the present case color power angiography of the cardiac hemangioma demonstrated blood flow. Although histological confirmation could not be obtained, the typical color flow mapping on postnatal ultrasound and typical characteristics displayed by MRI permitted the diagnosis of hemangioma. These tumors most commonly occur as polypoid masses adherent to the right atrial free walls or pericardium. They tend to be homogeneous, circumscribed, slightly more echogenic than myocardium and sometimes mixed with microcystic spaces. In most cases the vascular nature of the tumor is not demonstrable with color flow mapping as the abnormal vessels are microscopic. However, the main feeding vessel may readily be demonstrated as was seen in the present case. Differential diagnoses include other histological types of cardiac tumor such as rhabdomyoma, fibroma and teratoma. However, prenatal differentiation of hemangioma from these cardiac tumors may often be impossible and computed tomography scan or MRI may be useful for establishing the diagnosis2. Unlike cardiac rhabdomyoma, which regress postnatally, either partially or completely, cardiac hemangioma usually do not regress and usually require surgical removal. The present case was unusual in that the mass gradually regressed, resulting in complete resolution at 6 months. T. Tongsong*, S. Sirichotiyakul*, R. Sittiwangkul , C. Wanapirak*, * Department of Obstetrics Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand