Key points
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Most heart tumors are benign. Atrial myxomas make for 30%–50% of all primary cardiac tumors. (See Boxes 5.2 and 5.3 .)
Box 5.2
Coronary artery disease.
Coronary artery disease in cardiac tumors is determined by the patients’ symptomatology. According to the most recent clinical guidelines, assessment of the coronary vasculature is suitable in a patient with typical symptoms suggestive of coronary artery disease . On the other hand, many heart team approaches prefer to visualize coronary artery anatomy prior to surgical care in patients older than 40 years of age in order to diagnose and treat preclinical coronary artery disease concurrently with the operation
Box 5.3
Tumor feeding vessel.
The imaging of the feeding arteries by angiogram has a number of clinical and therapeutic implications. The placement of these vessels may alter the surgical strategy in cases where evidence of blood shunting exists, either as a result of fistula formation or spurting from the tumor surface. This may be the catalyst for many surgeons to ligate these feeding vessels during surgery in order to avert this problem . Separately, the proximity of a vascular supply to the tumor was associated with unusual clinical manifestations such as angina and sick sinus syndrome caused by blood shunting and subsequent myocardial and nodal ischemia . In cases when differentiating cardiac tumor from thrombus is difficult, the angiographic detection of neovessels favors the diagnosis of cardiac tumor over thrombi, which are frequently nonvascularized . Detection of a heart tumor’s blood supply also has therapeutic implications, as removing the feeding channel may impair tumor growth . Additionally, knowing the approximate position of a tumor in relation to its feeding channel provides information for predicting the tumor’s nature and behavior ( Table 5.1 )
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Knowing the approximate position of a tumor in relation to its feeding vessel provides information for predicting the tumor’s nature and behavior.
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Tumor blush is seen with benign atrial myxomas, hemangiomas, and rhabdomyomas, as well as malignant pheochromocytomas and angiosarcomas.
| It is widely known, particularly among surgical teams, that malignancies occasionally occur within the heart. Additionally, unlike general surgeons, many cardiac surgeons are unfamiliar with heart tumors . The heart is primarily composed of mesenchymal tissues, with the exception of the endocardium and pericardium, which are epithelial structures. This requirement for carcinomas is a distinguishing factor that can distinguish the heart from other organs. It is possible that this requirement for carcinomas contributes to the widespread belief that malignancies of the heart are infrequent . |
| Heart neoplasms are classified histologically as benign or malignant. They are far less common than secondary neoplasms, occurring at a rate of 0.001%–0.03%. Diagnosis is usually difficult, as patients remain asymptomatic for extended periods of time and frequently present with nonspecific signs and symptoms that may mimic those of other cardiac disease types. Around 75% of all cardiac tumors are benign. Atrial myxomas account for between 30% and 50% of all primary cardiac tumors. Lipomas, papillary fibroelastomas, fibromas, rhabdomyomas, and hemangiomas are all benign tumors. Sarcomas include leiomyosarcomas, rhabdomyosarcomas, osteosarcomas, and lymphomas, as well as primitive neuroectodermal tumors (pheochromocytomas) . |
| Tumor neovascularization and angiogenesis are critical for tumor growth. Coronary angiography of malignancies frequently reveals late opacification of a well-vascularized heart tumor, referred to as “tumor blush.” Certain cardiac neoplasms exhibit a distinctive “tumor blush”: benign myxomas, rhabdomyomas, and vascular malformations in the atrium and malignant pheochromocytomas and angiosarcomas in the atrium . The purpose of this chapter is to highlight the importance of coronary angiography in the workup of a cardiac tumor. |
| Type of tumor | Left atrium | Right atrium | Left ventricle | Right ventricle | Valve | Pericardium |
|---|---|---|---|---|---|---|
| Myxoma | 90% | 10% | Rare | Rare | Rare | 0 |
| Sarcoma | 46% a | 26% | 21% (right or left) b | b | 0 | 7% |
| Fibroma | Rare | Rare | 80% (majority in IVS) | 20% | 0 | 0 |
| Papillary fibroelastoma | 2% | c | 10% | 3% (right heart) c | 85% (AV, MV) | 0 |
| Rhabdomyoma d | 0 | 30% (atrium or ventricle) e | 70% (and ventricular septum) | c | 0 | 0 |
| Lipoma (LI)/ lipomatous hypertrophy (LM) | 0 | Majority LH | Epicardial surface (LI) | Epicardial surface (LI) | 0 | 0 |
| Angioma | Any location | Any location | Any location | Any location | Varix | 0 |
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