Home Giant right atrial hemangioma presenting with ascites: A case report
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Giant right atrial hemangioma presenting with ascites: A case report

  • Antonio Salsano EMAIL logo , Giacomo Perocchio , Antonio Guadagno , Paolo Nozza , Tommaso Regesta and Francesco Santini
Published/Copyright: July 23, 2025

Abstract

Introduction

Cardiac hemangiomas are slow-growing benign tumours of the heart. Patients may be asymptomatic or present a multitude of signs or symptoms.

Methods

We report herein the case of a 72-year-old woman with a giant right atrial mass. The patient suffers from abdominal swelling related to ascites. The histological examination of the tranjugular biopsy suspected an atrial myxoma.

Results

The patient was scheduled for surgical excision of the cardiac tumour. Radical resection of a 13 cm mass was performed. The histological diagnosis revealed cardiac hemangioma.

Conclusion

Cardiac hemangiomas can rarely grow larger than 5 cm, cause few symptoms, and are easily confused with atrial myxomas. Hepatomegaly and ascites may be signs of cardiac hemangioma.

1 Introduction

Cardiac hemangiomas are benign tumors with an incidence of around 3% of all cardiac tumors [1]. They are most commonly located in the right or left ventricle or in the right atrium [2]. The first report of cardiac hemangioma was published by Uskoff and colleagues in 1893 [3]. Cavernous hemangioma is the most common type [4]. Patients are mostly asymptomatic as cardiac hemangiomas are slow-growing tumors and usually do not metastasize. With an average size of 52.3 mm, they may seldom cause pericardial effusion, asymptomatic murmur, arrhythmias, hemopericardium or cardiac tamponade, dyspnea, complete heart block or even sudden death [5]. When symptoms occur, they are due to compression of cardiac structures or obstruction of outflow tracts [2]. Surgery is the treatment of choice because of the potential risk of embolism, rupture, and sudden death. Radiotherapy can be reserved for inoperable patients [6]. Other therapies include corticosteroids, β-blockers, interferon-α, anticancer drugs (such as vincristine, cyclophosphamide) [5,6].

We present a rare case of giant right atrial hemangioma in a patient symptomatic for ascites.

2 Case report

A 72-year-old woman, active smoker with a past medical history of COPD was admitted after 6 months of abdominal swelling related to ascites, swollen ankles and mild jaundice. The patient had no history of alcoholism. Liver ultrasonography showed a cirrhotic liver pattern with nodular hepatic contour and changes in volume distribution, without signs of hepatic hemangiomas. Blood tests revealed high bilirubin levels (2 mg/dl) with predominant direct bilirubin. Gastroscopy showed esophageal varices without bleeding. She reported no pain or dyspnea. Lung examination was unrevealing. Diuretic treatment was started. The electrocardiogram showed sinus rhythm, with signs of right ventricular strain. Chest computed tomography scan and magnetic resonance imaging (MRI, Figure 1) of the chest showed pleural effusion in the right side and a mass of 130 mm in the right atrium. Echocardiography showed a voluminous mass (130 mm × 110 mm) in the right atrium attached to the interatrial septum obstructing blood venous return through the inferior vena cava which appeared dilated. Troponine I values were negative. An ultrasound-guided tranjugular biopsy of the cardiac mass was performed, which excluded malignant mesenchymal tumors, sarcomas or organized clots. Histological examination suspected atrial myxoma. A positron emission tomography scan revealed heterogeneous moderate tracer’s accumulation in correspondence to the cardiac mass.

Figure 1 
               (a) and (b) Tumor in the MRI. RV: right ventricle; LV: left ventricle, LA: left atrium, RA: right atrium, arrow: interatrial septum, *: intracardiac mass.
Figure 1

(a) and (b) Tumor in the MRI. RV: right ventricle; LV: left ventricle, LA: left atrium, RA: right atrium, arrow: interatrial septum, *: intracardiac mass.

The patient was scheduled for surgical excision of the cardiac mass. Radical en bloc mass resection was achieved through a right atrial approach with resection of right atrial wall, pericardium and right pleura as the tumor eroded these structures and partially replaced them (Figure 2). The tumor peduncle was located on the atrial septum, eccentric with respect to the fossa ovalis. The tricuspid valve was not affected by the disease. It was necessary to reconstruct the wall of the right atrium and the superior and inferior atriocaval junctions with bovine pericardial patch. Surgery was performed with a median sternotomy access and the use of the cardio-pulmonary bypass. Ascending aorta, superior vena cava and right femoral vein were used as arteriovenous cannulation sites. Cardiopulmonary bypass (CPB) was used and Custodiol cardioplegia was administered in the ascending aorta after clamping. CPB time was 190 min. The excised mass had a dimension of 13 cm × 7 cm × 6 cm and a weight of about one kilo. It was purplish in color, of elastic consistency with dark red spongy sections (Figure 3). The histological diagnosis was cardiac hemangioma (Figure 4).

Figure 2 
               Surgical view of the cardiac tumour. White arrow: right atrial wall, yellow arrow: atrial wall eroded by the neoplasm.
Figure 2

Surgical view of the cardiac tumour. White arrow: right atrial wall, yellow arrow: atrial wall eroded by the neoplasm.

Figure 3 
               Excised mass.
Figure 3

Excised mass.

Figure 4 
               Microscope Specimen. The section shows a well-circumscribed tumor, composed of lobules of cystically dilated vascular spaces filled with blood (*) and lined by flat endothelial cells (arrow) without cytological atypia (Hematoxylin & Eosin, 100×).
Figure 4

Microscope Specimen. The section shows a well-circumscribed tumor, composed of lobules of cystically dilated vascular spaces filled with blood (*) and lined by flat endothelial cells (arrow) without cytological atypia (Hematoxylin & Eosin, 100×).

Postoperative course was uneventful. Postoperative echocardiographic examination showed no residual mass in the right atrium, moderate tricuspid regurgitation due to chordal rupture. At 1 year follow-up the patient is alive and asymptomatic. Cancer recurrence or relapse did not occur.

  1. Informed consent: Explicit informed consent and authorization for the use of the photographic image were obtained from the participating patient.

3 Discussion

Secondary cardiac tumors are much more common than primary ones. In autopsy series, three-quarters of primary cardiac tumors are benign, mostly myxomas, and one-quarter are malignant [1]. Cardiac hemangioma is a rare tumor that originates from abnormal hyperplasia or dilatation of small arterioles, venules and capillaries. It represents 1–2% of primary cardiac tumors which in turn have an incidence of 17 in a million on autopsy findings [1,46].

It occurs at all ages but it is mostly diagnosed in middle-aged patients [7,8]. The differential diagnosis includes cardiac thrombus and atrial myxoma. Hemangioma can be confused with the latter especially if a peduncle attached to the interatrial septum is present [5]. The natural history of cardiac hemangioma is unknown although it appears to be a slow-growing tumour. In most cases it is localized in the right heart and patients were usually asymptomatic. Symptoms may occur for obstruction of the cardiac chambers which impairs the blood flow [6,9,10]. Signs and symptoms include decreased exercise tolerance, syncope, angina, stroke, systemic embolism, cyanosis, attack of stuffiness, nausea and vomiting, heart murmur, systemic congestion, right ventricular outflow tract obstruction which resembles pulmonary stenosis, shortness of breath, pericardial effusion and hemopericardium, renal failure, sudden death, atrioventricular block, myocardial ischemia by direct coronary compression, coronary steal, Ebstein’s anomaly, consumptive coagulopathy [1120]. In our case the patient presented signs such as abdominal swelling, ascites and hyperbilirubinemia, usually pathognomonic of malignant tumors of the abdomen. Due to this, the diagnosis of cardiac hemangioma was not immediately suspected, moving towards an abdominal pathology.

Hemangiomas are usually 5 cm or less in size [5]. In the present case, this 13 cm large giant cardiac tumour did not cause severe symptoms. Haemangiomas with heterogeneous shapes and behaviours are described in the literature. This kind of tumours can develop longitudinally and enter the valvular orifices mimicking a valvular pathology or enlarge and erode the surrounding cardiac structures as in this case, where a portion of the neoplasm replaced the atrial wall.

Successful conservative management has been reported with the use of corticosteroids, β-blockers, interferon-α, and anticancer drugs [5]. The cornerstone of the treatment of infants with haemangioma is the glucocorticoid therapy and only about 16% of haemangioma patients do not respond to glucocorticoid [21]. Beta-receptor blockers have more recently replaced glucocorticoids for propranolol as first-line agents to treat hemangiomas [22]. Interferon-α inhibits angiogenesis by suppressing the proliferation of haemangiomas [23].

Vincristine, cyclophosphamide, bevacizumab, and rapamycin can reduce the dose of glucocorticoids, even contribute to glucocorticoids withdrawal [24].

In adults, the treatment of choice remains surgery in presence of symptoms and diagnostic uncertainty. Surgery can be complex due to the amount of structures to be reconstructed [25]. Due to the anatomy and the high risk of sudden cardiac death, our patient underwent surgical excision. Depending on the location of the tumour, the surgical incision may vary. A median sternotomy is the standard access, minimally invasive surgery via a lateral thoracotomy may be considered. A left transatrial approach could be considered if the tumour is situated close to the the mitral valve, a right atriotomy is mandatory for the tumours of the right atrium or interatrial septum, and a ventriculotomy is necessary for the ones located in the ventricles [25,26].

4 Conclusions

Cardiac hemangiomas can reach considerable dimensions. Very often they are confused with atrial myxomas because of a pedicle attached to the interatrial septum. Preoperative biopsy may be inconclusive and suspect the wrong tumour. Right atrial giant hemangiomas are rare but should be considered in the differential diagnosis of ascites in patients with unknown cirrhotic disease. Surgical treatment resulted to be safe and effective.


# Equal contributors.


  1. Funding information: The authors state no funding involved.

  2. Author contributions: Antonio Salsano, Giacomo Perocchio, Tommaso Regesta, Francesco Santini conceptualized the case report, drafted the initial manuscript, critically reviewed the manuscript, gave final approval, and agreed to be held accountable for all aspects of the work. Antonio Guadagno and Paolo Nozza collected the data and graphically presented the data, critically reviewed the manuscript and gave final approval. All authors read and approved the final manuscript.

  3. Conflict of interest: Antonio Salsano is Editor in Open Medicine, but this fact did not influence peer-review process.

  4. Data availability statement: Data of the current study are available from the corresponding author on reasonable request.

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Received: 2024-08-23
Revised: 2025-02-23
Accepted: 2025-02-25
Published Online: 2025-07-23

© 2025 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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  133. Anticancer activity mechanism of novelly synthesized and characterized benzofuran ring-linked 3-nitrophenyl chalcone derivative on colon cancer cells
  134. H2valdien3 arrests the cell cycle and induces apoptosis of gastric cancer
  135. Prognostic relevance of PRSS2 and its immune correlates in papillary thyroid carcinoma
  136. Association of SGLT2 inhibition with psychiatric disorders: A Mendelian randomization study
  137. Motivational interviewing for alcohol use reduction in Thai patients
  138. Luteolin alleviates oxygen-glucose deprivation/reoxygenation-induced neuron injury by regulating NLRP3/IL-1β signaling
  139. Polyphyllin II inhibits thyroid cancer cell growth by simultaneously inhibiting glycolysis and oxidative phosphorylation
  140. Relationship between the expression of copper death promoting factor SLC31A1 in papillary thyroid carcinoma and clinicopathological indicators and prognosis
  141. CSF2 polarized neutrophils and invaded renal cancer cells in vitro influence
  142. Proton pump inhibitors-induced thrombocytopenia: A systematic literature analysis of case reports
  143. The current status and influence factors of research ability among community nurses: A sequential qualitative–quantitative study
  144. OKAIN: A comprehensive oncology knowledge base for the interpretation of clinically actionable alterations
  145. The relationship between serum CA50, CA242, and SAA levels and clinical pathological characteristics and prognosis in patients with pancreatic cancer
  146. Identification and external validation of a prognostic signature based on hypoxia–glycolysis-related genes for kidney renal clear cell carcinoma
  147. Engineered RBC-derived nanovesicles functionalized with tumor-targeting ligands: A comparative study on breast cancer targeting efficiency and biocompatibility
  148. Relationship of resting echocardiography combined with serum micronutrients to the severity of low-gradient severe aortic stenosis
  149. Effect of vibration on pain during subcutaneous heparin injection: A randomized, single-blind, placebo-controlled trial
  150. The diagnostic performance of machine learning-based FFRCT for coronary artery disease: A meta-analysis
  151. Comparing biofeedback device vs diaphragmatic breathing for bloating relief: A randomized controlled trial
  152. Serum uric acid to albumin ratio and C-reactive protein as predictive biomarkers for chronic total occlusion and coronary collateral circulation quality
  153. Multiple organ scoring systems for predicting in-hospital mortality of sepsis patients in the intensive care unit
  154. Single-cell RNA sequencing data analysis of the inner ear in gentamicin-treated mice via intraperitoneal injection
  155. Review Articles
  156. The effects of enhanced external counter-pulsation on post-acute sequelae of COVID-19: A narrative review
  157. Diabetes-related cognitive impairment: Mechanisms, symptoms, and treatments
  158. Microscopic changes and gross morphology of placenta in women affected by gestational diabetes mellitus in dietary treatment: A systematic review
  159. Review of mechanisms and frontier applications in IL-17A-induced hypertension
  160. Research progress on the correlation between islet amyloid peptides and type 2 diabetes mellitus
  161. The safety and efficacy of BCG combined with mitomycin C compared with BCG monotherapy in patients with non-muscle-invasive bladder cancer: A systematic review and meta-analysis
  162. The application of augmented reality in robotic general surgery: A mini-review
  163. The effect of Greek mountain tea extract and wheat germ extract on peripheral blood flow and eicosanoid metabolism in mammals
  164. Neurogasobiology of migraine: Carbon monoxide, hydrogen sulfide, and nitric oxide as emerging pathophysiological trinacrium relevant to nociception regulation
  165. Plant polyphenols, terpenes, and terpenoids in oral health
  166. Laboratory medicine between technological innovation, rights safeguarding, and patient safety: A bioethical perspective
  167. End-of-life in cancer patients: Medicolegal implications and ethical challenges in Europe
  168. The maternal factors during pregnancy for intrauterine growth retardation: An umbrella review
  169. Intra-abdominal hypertension/abdominal compartment syndrome of pediatric patients in critical care settings
  170. PI3K/Akt pathway and neuroinflammation in sepsis-associated encephalopathy
  171. Screening of Group B Streptococcus in pregnancy: A systematic review for the laboratory detection
  172. Giant borderline ovarian tumours – review of the literature
  173. Leveraging artificial intelligence for collaborative care planning: Innovations and impacts in shared decision-making – A systematic review
  174. Cholera epidemiology analysis through the experience of the 1973 Naples epidemic
  175. Risk factors of frailty/sarcopenia in community older adults: Meta-analysis
  176. Supplement strategies for infertility in overweight women: Evidence and legal insights
  177. Scurvy, a not obsolete disorder: Clinical report in eight young children and literature review
  178. A meta-analysis of the effects of DBS on cognitive function in patients with advanced PD
  179. Protective role of selenium in sepsis: Mechanisms and potential therapeutic strategies
  180. Strategies for hyperkalemia management in dialysis patients: A systematic review
  181. C-reactive protein-to-albumin ratio in peripheral artery disease
  182. Case Reports
  183. Delayed graft function after renal transplantation
  184. Semaglutide treatment for type 2 diabetes in a patient with chronic myeloid leukemia: A case report and review of the literature
  185. Diverse electrophysiological demyelinating features in a late-onset glycogen storage disease type IIIa case
  186. Giant right atrial hemangioma presenting with ascites: A case report
  187. Laser excision of a large granular cell tumor of the vocal cord with subglottic extension: A case report
  188. EsoFLIP-assisted dilation for dysphagia in systemic sclerosis: Highlighting the role of multimodal esophageal evaluation
  189. Molecular hydrogen-rhodiola as an adjuvant therapy for ischemic stroke in internal carotid artery occlusion: A case report
  190. Coronary artery anomalies: A case of the “malignant” left coronary artery and its surgical management
  191. Rapid Communication
  192. Biological properties of valve materials using RGD and EC
  193. A single oral administration of flavanols enhances short-term memory in mice along with increased brain-derived neurotrophic factor
  194. Letter to the Editor
  195. Role of enhanced external counterpulsation in long COVID
  196. Expression of Concern
  197. Expression of concern “A ceRNA network mediated by LINC00475 in papillary thyroid carcinoma”
  198. Expression of concern “Notoginsenoside R1 alleviates spinal cord injury through the miR-301a/KLF7 axis to activate Wnt/β-catenin pathway”
  199. Expression of concern “circ_0020123 promotes cell proliferation and migration in lung adenocarcinoma via PDZD8”
  200. Corrigendum
  201. Corrigendum to “Empagliflozin improves aortic injury in obese mice by regulating fatty acid metabolism”
  202. Corrigendum to “Comparing the therapeutic efficacy of endoscopic minimally invasive surgery and traditional surgery for early-stage breast cancer: A meta-analysis”
  203. Corrigendum to “The progress of autoimmune hepatitis research and future challenges”
  204. Retraction
  205. Retraction of “miR-654-5p promotes gastric cancer progression via the GPRIN1/NF-κB pathway”
  206. Retraction of: “LncRNA CASC15 inhibition relieves renal fibrosis in diabetic nephropathy through downregulating SP-A by sponging to miR-424”
  207. Retraction of: “SCARA5 inhibits oral squamous cell carcinoma via inactivating the STAT3 and PI3K/AKT signaling pathways”
  208. Special Issue Advancements in oncology: bridging clinical and experimental research - Part II
  209. Unveiling novel biomarkers for platinum chemoresistance in ovarian cancer
  210. Lathyrol affects the expression of AR and PSA and inhibits the malignant behavior of RCC cells
  211. The era of increasing cancer survivorship: Trends in fertility preservation, medico-legal implications, and ethical challenges
  212. Bone scintigraphy and positron emission tomography in the early diagnosis of MRONJ
  213. Meta-analysis of clinical efficacy and safety of immunotherapy combined with chemotherapy in non-small cell lung cancer
  214. Special Issue Computational Intelligence Methodologies Meets Recurrent Cancers - Part IV
  215. Exploration of mRNA-modifying METTL3 oncogene as momentous prognostic biomarker responsible for colorectal cancer development
  216. Special Issue The evolving saga of RNAs from bench to bedside - Part III
  217. Interaction and verification of ferroptosis-related RNAs Rela and Stat3 in promoting sepsis-associated acute kidney injury
  218. The mRNA MOXD1: Link to oxidative stress and prognostic significance in gastric cancer
  219. Special Issue Exploring the biological mechanism of human diseases based on MultiOmics Technology - Part II
  220. Dynamic changes in lactate-related genes in microglia and their role in immune cell interactions after ischemic stroke
  221. A prognostic model correlated with fatty acid metabolism in Ewing’s sarcoma based on bioinformatics analysis
  222. Red cell distribution width predicts early kidney injury: A NHANES cross-sectional study
  223. Special Issue Diabetes mellitus: pathophysiology, complications & treatment
  224. Nutritional risk assessment and nutritional support in children with congenital diabetes during surgery
  225. Correlation of the differential expressions of RANK, RANKL, and OPG with obesity in the elderly population in Xinjiang
  226. A discussion on the application of fluorescence micro-optical sectioning tomography in the research of cognitive dysfunction in diabetes
  227. A review of brain research on T2DM-related cognitive dysfunction
  228. Metformin and estrogen modulation in LABC with T2DM: A 36-month randomized trial
  229. Special Issue Innovative Biomarker Discovery and Precision Medicine in Cancer Diagnostics
  230. CircASH1L-mediated tumor progression in triple-negative breast cancer: PI3K/AKT pathway mechanisms
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