Clinical presentation of rhabdomyoma of the heart in infancy and childhood

Loss of Consciousness in the Young Child

In the very young child (less than eight years of age), transient loss of consciousness represents a diagnostic and management dilemma for clinicians. While most commonly benign, syncope may be due to cardiac dysfunction which can be life-threatening. It can be secondary to an underlying ion channelopathy, cardiac inflammation, cardiac ischemia, congenital heart disease, cardiomyopathy, or pulmonary hypertension. Patients with genetic disorders require careful evaluation for a cardiac cause of syncope. Among the noncardiac causes, vasovagal syncope is the most common etiology. Breath-holding spells are commonly seen in this age group. Other causes of transient loss of consciousness include seizures, neurovascular pathology, head trauma, psychogenic pseudosyncope, and factitious disorder imposed on another and other forms of child abuse. A detailed social, present, past medical, and family medical history is important when evaluating loss of consciousness in the very young. Concerning characteristics of syncope include lack of prodromal symptoms, no preceding postural changes or occurring in a supine position, after exertion or a loud noise. A family history of sudden unexplained death, ion channelopathy, cardiomyopathy, or congenital deafness merits further evaluation. Due to inherent challenges in diagnosis at this age, often there is a lower threshold for referral to a specialist.

Surgery for Primary Cardiac Tumors in Children

Background—

To evaluate indications and results of surgery for primary cardiac tumors in children.

Methods and Results—

Eighty-nine patients aged ≤18 years undergoing surgery for cardiac tumor between 1990 and 2005 from 16 centers were included retrospectively (M/F=41/48; median age 4.3 months, range 1 day to 18 years). Sixty-three patients (68.5%) presented with symptoms. Surgery consisted of complete resection in 62 (69.7%) patients, partial resection in 21 (23.6%), and cardiac transplant in 4 (4.5%). Most frequent histotypes (93.2%) were benign (rhabdomyoma, myxoma, teratoma, fibroma, and hemangioma). Postoperative complications occurred in 29.9%. Early and late mortality were 4.5% each (mean follow-up, 6.3±4.4 years); major adverse events occurred in 28.2% of the patients; 90.7% of patients are in New York Heart Association class I. There were no statistically significant differences in survival, postoperative complications, or adverse events after complete and partial resection in benign tumors other than myxomas. Cardiac transplant was associated significantly with higher mortality rate ( P= 0.006). Overall mortality was associated to malignancy ( P =0.0008), and adverse events during follow-up ( P =0.005).

Conclusions—

Surgery for primary cardiac tumors in children has good early and long-term outcomes, with low recurrence rate. Rhabdomyomas are the most frequent surgical histotypes. Malignant tumors negatively affect early and late survival. Heart transplant is indicated when conservative surgery is not feasible. Lack of recurrence after partial resection of benign cardiac tumors indicates that a less risky tumor debulking is effective for a subset of histotypes such as rhabdomyomas and fibromas.

Left ventricular outflow obstruction in rhabdomyoma of infancy: meta-analysis of the literature

Primary heart tumors are exceptional in infants and children. Most common is the rhabdomyoma, often associated with tuberous sclerosis (Bourneville's disease). This tumor is generally believed to have no hemodynamic effects in the majority of cases. Recently, severe obstruction of the left ventricular outflow tract by a solitary tumor was diagnosed during pregnancy and emergency surgery was needed soon after birth.

Primary rhabdomyosarcoma of the heart presenting with increased intracranial pressure

An 18-month-old boy presented with signs of increased intracranial pressure. Computed tomographic scans of the brain and lungs showed multiple masses in the brain and lungs. Echocardiography revealed homogeneous, irregular pericardial thickening, minimal pericardial effusion, and irregular echogenic areas in the left ventricular inferoposterior and apical regions. Postmortem examination of tumor tissue showed that the masses were primary rhabdomyosarcoma of the left ventricle with multiple metastases. Primary rhabdomyosarcoma of the heart is uncommon, especially in patients under 2 years of age.

Surgical treatment for cardiac rhabdomyomas in children

Cardiac rhabdomyomas are the most common cardiac tumor in children. These tumors may cause obstruction to blood flow, valvular insufficiency, and cardiac arrhythmias. We present two cases of cardiac rhabdomyomas in infants that were managed surgically and review the literature. Without surgical intervention, the prognosis for symptomatic cardiac rhabdomyomas is dismal, with eventual death likely due to heart failure or arrhythmias. As our two cases indicate, surgical treatment may improve this prognosis. Pediatric cardiac rhabdomyomas should be resected when the tumors cause hemodynamic compromise or cardiac arrhythmias.

Neurocutaneous syndromes

Many of the neurocutaneous disorders are more common than once suspected, in part because patients with milder forms of the disorders are now more likely to be recognized. Improved diagnostic studies and increasingly specific medical and surgical therapy allow some previously untreatable complications to be successfully managed. Genetic linkage analysis has localized the abnormal gene for some of the hereditary neurocutaneous disorders onto specific chromosomes, and newly developed clinical diagnostic criteria have improved our ability to establish a definite diagnosis in less obvious patients. Thus, the outlook for these patients is no longer uniformly pessimistic.

Hypoplastic left heart syndrome with rhabdomyoma of the left ventricle

A case of primary cardiac tumor with hypoplastic left heart syndrome (HLH) is presented. Sonographic examination at 32 weeks' gestation revealed a large tumor in the left ventricle of the fetal heart. The newborn died of congestive heart failure at 11 days of age. Autopsy demonstrated a large tumor in the left ventricle obliterating most of the left ventricular cavity, aortic atresia, and hypoplastic ascending aorta. Microscopically, the cardiac tumor showed "spider-cells" characteristics of rhabdomyoma.

Natural history of cardiac rhabdomyoma in infancy and childhood

Although spontaneous regression of cardiac rhabdomyoma has been reported, prognosis is still considered to be poor and surgery continues to be indicated. The experience with rhabdomyoma diagnosed in live infants over a 20-year period was reviewed. Diagnosis by angiography or echocardiography was accepted only if multiple tumors were present or if tuberous sclerosis was also diagnosed. Nine patients (3 diagnosed prenatally and the remaining 6 at age less than 8 months) were identified as having a total of 24 tumors. Measurements in 2 planes demonstrated at least some evidence of regression in 24 patients (100%), with 20 of 24 having complete resolution. One patient required delayed surgery for excision of a subaortic ridge that appeared at the site of a resolved tumor. Our findings suggest that pediatric cardiac rhabdomyoma is most often a benign condition in which spontaneous regression is the rule. Surgery is recommended only for patients with refractory dysrhythmias or severe hemodynamic compromise.

Intracardiac fibroma in an asymptomatic infant

Primary tumors of the heart are rare in infancy and childhood. A one-year-old, asymptomatic, male infant with unimpressive physical findings in whom an echocardiogram demonstrated a large, encapsulated, solid fibroma filling the right ventricle without obstruction of either the inflow or outflow tract is presented. Successful complete surgical excision of the tumor was accomplished. The histological examination was compatible with a benign fibroma. The infant has remained asymptomatic postoperatively with subsidence of the heart murmur. He has not shown any evidence of recurrence of the tumor during a follow-up period of 29 months. This represents an unusual case of a huge right ventricular fibroma and only the fifth youngest patient, to our knowledge, to undergo successful surgical removal.

Subaortic stenosis by solitary rhabdomyoma. Successful excision in an infant following 2D echocardiogram and Doppler diagnosis

A seven-month-old girl had subaortic stenosis caused by a single intracavitary rhabdomyoma unassociated with tuberous sclerosis. Diagnosis was formulated on the basis of two-dimensional echocardiography and Doppler technique findings alone, and surgery was successful.

Spontaneous regression of cardiac rhabdomyoma in tuberous sclerosis

Life-threatening cardiac rhabdomyoma in a newborn infant regressed spontaneously within a 5 month period. Since cardiac surgery for rhabdomyoma is dangerous in infancy, medical management should be considered if symptomatology is not severe. When a fetal arrhythmia is diagnosed, antenatal ultrasound examination for presence of cardiac tumors is warranted.

Cerebral embolism resulting from an intracardiac tumor in tuberous sclerosis

Tuberous sclerosis was diagnosed in an infant girl during the first 3 days of life on the basis of electrocardiographic and cranial computed tomographic abnormalities. At 19 months of age, neurologic deterioration occurred and repeat computed tomography documented several new cortical lesions while the subaortic mass was markedly reduced in size. The sequence of events suggested cerebral embolization by the cardiac tumor.

Echocardiography of intracardiac filling defects in infants and children

Intracardiac masses are rare in infants and children. Early detection is essential to their successful management. We present seven patients in whom echocardiography established the diagnosis and was crucial in the management. Three of the masses were primary cardiac tumors and four were thrombi. Patient 1: an infant with a calcified left ventricular fibroma. Patient 2: a neonate who presented with cyanosis due to obstruction of the right ventricular inflow tract by a fibroblastic tumor. Patient 3: an infant with a right atrial myxoma presenting as sepsis. Patient 4: a child who had a pulmonary embolus after a pulmonary valvotomy and was found to have a right ventricular thrombus. Patient 5: a child with a right atrial thrombus following a Fontan procedure for univentricular atrioventricular connection. Patient 6: a child with a left ventricular thrombus due to a dilated cardiomyopathy in association with epidermolysis bullosa. Patient 7: An infant with bilateral lobar emphysema, an aorticopulmonary window with left ventricular fibroelastosis, who developed a left ventricular thrombus.

Fetal tachycardia and intramyocardial tumors

The two-dimensional echocardiographic diagnosis of multiple cardiac rhabdomyomas and evaluation of tachycardia in a fetus are presented. Prenatal echocardiographic examination defined the extent of tumor involvement and mechanism of the tachycardia and demonstrated the lack of fetal hemodynamic compromise. Perinatal, clinical and therapeutic implications are discussed.

Cardiac rhabdomyoma in the neonate: surgical management

Rhabdomyoma is the most common cardiac neoplasm in neonates. Tuberous sclerosis is found in half of the patients with rhabdomyomas. We maintain a surgical policy of accepting for operation only neonates in whom it has been demonstrated that the primary cause for hemodynamic compromise is obstructing, intracavitary neoplasms. Only the intracavitary portions of the rhabdomyoma are excised; no effort is made to completely remove all intramural tumors. Rhabdomyomas demonstrate benign pathological characteristics and may regress. Neonates with rhabdomyomas but no hemodynamic impairment, or those in whom only intramural masses can be demonstrated, are not considered surgical candidates. Tuberous sclerosis by itself should not be judged a contraindication to operation. The results of our surgical policy regarding rhabdomyomas in neonates are reported in two case presentations.

Two-dimensional echocardiographic diagnosis of intracardiac masses in infancy

Intracardiac masses in infancy are uncommon. Tumors, thrombi and vegetations of bacterial endocarditis are exceedingly rare in this age group. These masses are seldom diagnosed before the infant's death. In a review of two-dimensional echocardiograms performed from May 1979 to January 1981 on 741 infants less than 2 years of age, intracardiac masses were prospectively identified in 6 patients. All six patients presented with unexplained murmurs associated with either hemodynamic instability, arrhythmias or systemic emboli. One patient had a vegetation from bacterial endocarditis, one had an intracardiac thrombus associated with myocarditis, three had rhabdomyomas (two patients with tuberous sclerosis) and one had a fibro-fatty nodule attached to the eustachian valve. Two-dimensional echocardiography not only was important in the diagnosis, but also provided guidance in the medical and surgical treatment of these patients.

Rhabdomyoma of the heart producing right bundle branch block

A 4-day-old female had an uneventful prenatal course and delivery. Immediate cyanosis improved with oxygen therapy. Cardiomegaly on chest radiograph, right bundle branch block on electrocardiogram, and apparent increased tricuspid valve excursion on echocardiography led to a diagnosis of Ebstein's anomaly. Death occurred unexpectedly. Autopsy demonstrated a rhabdomyoma of the interventricular septum, which had produced obstruction to right ventricular outflow and had interrupted the right bundle branch of the conducting system. It appears that the massive size of the septal tumor led to its misdiagnosis on the echocardiogram.

Investigation and management of primary cardiac tumors in infants and children

Seven children with primary cardiac tumors are discussed. The diagnosis was achieved by cardiac catheterization in all seven patients. In four patients, surgical excision was undertaken with one long-term good result. One of the other three surgical patients died of acute heart failure at the discontinuation of cardiopulmonary bypass. One of the other two surgical patients died suddenly late postoperatively, presumably from arrhythmia. The other, affected by fibrosarcoma, also died suddenly while undergoing chemotherapy. The histologic findings on the tumor masses were available in six patients. There were three rhabdomyomas, one fibrosarcoma, one fibroma and one hamartomatous mass. In one patient with tuberous sclerosis, a presumptive diagnosis of rhabdomyoma was made clinically on the basis of multiple masses infiltrating the left ventricle. Two-dimensional echocardiography is the best noninvasive tool to determine the extent and location of the tumor and suitability for surgery. When surgery is indicated, cardiac catheterization for pressure data is also required. Surgery is recommended in symptomatic solitary lesions that most likely are fibromas and have an overall good surgical outcome.

Primary rhabdomyosarcoma of the heart

A primary rhabdomyosarcoma of the heart observed in a 3-week-old infant, provides an opportunity to review this rare clinical entity; 61 reported cases are collated. The more common sites are right ventricle, left atrium, and right atrium; the tumour may protrude into the cavity and cause obstruction. Echocardiography can demonstrate the tumour, which may also been seen as a filling defect on angiography. Primary heart tumours seldom occur, especially in infancy and childhood. According to Van der Hauwaert, the most common cardiac tumour in infancy is the rhabdomyoma. No primary malignant tumour was seen in 15 European centres within a 5-year period.

Primary cardiac tumours in infancy and childhood. A review and six case reports

Primary cardiac tumours are rarities in infants and children. We have had 6 patients, aged 17 days to 10 years, with primary cardiac tumours: 1 had a fibroma, 1 had a myxoma, 2 had an haemangioma and 2 had a rhabdomyoma. Correct diagnosis was missed pre-operatively in 3 cases and finally established at autopsy. Three of the patients underwent cardiac operation-one of them unsuccessfully. At surgery the main difficulties were with tumour infiltration and the multifocal nature of some tumours. We conclude that the echo- and angiocardiography are essential tools in the diagnosis of primary cardiac tumours. Large tumours or conduction tissue infiltration means an extremely poor prognosis. Multifocal cardiac tumours can be successfully removed, even in newborn babies, and the outcome for the patients is also affected by other important factors, e.g. tuberous sclerosis in rhabdomyomas.

Solitary rhabdomyoma of the heart. Clinically silent case with sudden, unexpected death in an 11-month-old boy

We report a case of cardiac rhabdomyoma leading to sudden, unexpected death in an 11-month-old child. Autopsy disclosed a firm nodular tumor located in the anterior part of the interventricular septum and anterior wall of the left chamber. The tumor bulged into the cavity of the ventricle and caused appreciable narrowing of the outflow tract. Histologically, the typical "spider cells" characteristic for cardiac rhabdomyoma could be found. Sections cut from alcohol-fixed tissues and stained in water-free PAS showed that these cells contained massive amounts of diastase-digestible PAS-positive material, presumably glycogen. No evidence of tuberous sclerosis was detected. Sudden death was attributed to cardiac arrest due to irritation of the conducting system by the tumor.

Imaging procedures in the detection of cardiac tumors, with emphasis on echocardiography: a review

Although cardiac tumors are relatively rare, their diagnosis is important because successful treatment is usually feasible if the diagnosis is made preoperatively. An analysis of 219 reports of cardiac tumors described in the English literature from 1972 through 1977 demonstrated the predominance of benign tumors, in particular myxoma, which is in agreement with past reviews. The methods of diagnosis employed included plain chest films, echocardiography, cardiac catheterization, angiocardiography, and cardiac scintigraphy. Conventional x-ray examination of the chest was abnormal in 83% of cardiac tumors but non-specific and should lead to further evaluation, first by echocardiography. Echocardiography, the most efficient diagnostic procedure for screening possible cardiac tumors, was abnormal in 94% of the cases. Cardiac catheterization was abnormal in 80% of cardiac tumors while definitive detection was made by angiocardiography in 94% of the cases. Cardiac scintigraphy has had limited use in the diagnosis of cardiac tumors, but has been diagnostic in 100% of the cases in a small series of myxomas.

Primary cardiac tumors

Cardiac tumors are a rare, but potentially curably form of heart disease. A high index of clinical suspicion is necessary for diagnosis as these tumors have protean manifestations that mimic a variety of other cardiac and noncardiac diseases. Presently, M-mode and two-dimensional echocardiography are utilized as safe, reliable, and noninvasive imaging modalities. Seventy-five per cent of these tumors are benign, with myxoma accounting for 50% and rhabodomyoma comprising 20% of lesions. Various histologic types of sarcoma are the predominant malignant cardiac neoplasms. With strict attention to avoiding perioperative tumor embolization, surgical resection of these lesions can be accomplished with minimal morbidity and mortality. Sixteen consecutive primary tumors of the heart have been surgically treated at Duke University Medical Center since 1966 with no perioperative deaths and no late recurrences.

Alveolar rhabdomyosarcoma involving the heart. An echocardiographic, angiographic and pathologic study

A 12-year-old girl, who had had an above-knee amputation of the left leg for a soft tissue sarcoma six years prior to this admission, presented with syncope, angina, and signs of aortic stenosis. Echocardiography demonstrated a mass arising from the interventricular septum with obstruction of the left ventricular outflow tract and aortic valve. Cardiac catheterization and angiography confirmed these findings. At operation, a tumor was found involving the interventricular septum. Histologically, it was an alveolar rhabdomyosarcoma, and it appeared similar to the previous tumor. The patient was treated by partial surgical resection, cytotoxic drugs and localized radiation therapy and has been followed by serial echocardiography.

Cardiac rhabdomyoma: a clinicopathologic and electron microscopic study

Cardiac rhabdomyomas are rare tumors of infancy. In a series of 36 patients 78 percent were under 1 year of age, and only one patient was over age 15 years. Ninety percent of the rhabdomyomas were multiple and occurred with nearly equal frequency in the right and left ventricles. Although reportedly infrequent in the atria, rhabdomyomas involved either one or both atria in 30 percent of patients. In 50 percent of patients at least one of the tumor masses was intracavitary and obstructed 50 percent or more of one of the cardiac chambers or valve orifices. Symptoms referable to obstruction of intracardiac blood flow were present in nine patients, none of whom had tuberous sclerosis, and all of whom would appear to have been good surgical candidates. Histologically the rhabdomyomas were composed of classic "spider cells". Electron microscopic studies revealed scattered bundles of myofibrils ringing these cells and radiating toward the center; glycogen was present both free in the cytoplasm and within mitochondria. Distinct intercellular junctions resembling intercalated discs with well defined desmosomes and nexuses were present. Many of the cells contained leptofibrils, arranged either peripherally or in spiraled clusters in the center of the cell. Rhabdomyomas derive from cardiac muscle cells and appear to represent hamartomas rather than true tumors.

Primary rhabdomyosarcoma of the heart: a case report, with autopsy

A case of rhabdomyosarcoma of the heart in a 45-year-old man is reported. The diagnosis was suspected because of refractory congestive cardiac failure, a bulge on the left cardiac border, and was confirmed histologically at necropsy.