https://orcid.org/0000-0001-5761-5311
Case description
A 58-year-old male presented with chest pain. He had a recent history of colectomy for rectosigmoid cancer. He also underwent a left pneumonectomy for two lung nodules: one was metastasis from the colon cancer, and the other was a primary squamous cell carcinoma of the lung. Electrocardiogram showed no dynamic changes, while troponin was elevated. A transthoracic contrast echocardiogram (due to the poor acoustic window) was performed that showed mildly reduced left ventricular (LV) systolic function and no significant valvular disease or pericardial fluid. A hyperechoic mass of circular/crescent shape and of inhomogeneous substance was revealed at the apical anterolateral LV wall that was enhanced using contrast medium (Panels A1 and A2, Supplementary data online, Video S1). Our tentative diagnoses encompassed congenital or iatrogenic arteriovenous fistulas (including coronary fistulas) and cardiac vascular tumours (either benign such as haemangiomas or malignant such as metastatic lesions or angiosarcomas). Coronary angiography showed only a malformation with characteristic vascular blush in proximity to the distal left anterior descending artery, coming to confirm echocardiographic findings (Panels B1 and B2, Supplementary data online, Video S2). A computed tomography (CT) pulmonary angiography was also performed, which excluded pulmonary embolism (there was no contrast enhancement during the venous phase of this CT—Panel C). A PET–CT scan was performed that failed to show hypermetabolism, thus excluding possible metastasis (Panel D). Since malignancy was excluded and our patient was asymptomatic with many comorbidities, a conservative treatment was decided.
Benign vascular cardiac malformations are either haemangiomas or coronary fistulas in most of the cases. Symptoms related to coronary shunting may be an indication for treatment, and in patients with cancer, a metastasis must be excluded (by using multimodality imaging) to make the final decision.
Supplementary data
Supplementary data are available at European Heart Journal – Imaging Methods and Practice online.
Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with Committee on Publication Ethics guidance.
Funding: None declared.
Data availability
The data underlying this article are available in the article and in its online Supplementary material.
Lead author biography
Vasileios Bouratzis graduated from the University of Ioannina Medical School in 2016, and now he is a cardiologist trainee at the University Hospital of Ioannina, Greece. His main interests are coronary artery disease, cardiogenic shock, and cardioncology.
Author notes
Conflict of interest: None declared.
