JACC: CASE REPORTS

VOL. 2, NO. 10, 2020

ª 2020 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICANCOLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDERTHE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).

MINI-FOCUS ISSUE: IMAGINGIMAGING VIGNETTE: CLINICAL VIGNETTE

Invasive Cardiac Lipoma Complicating
Visceral Inversion
Takahide Kadosaka, MD,a Shingo Tsujinaga, MD, PHD,a Hiroyuki Iwano, MD, PHD,aNoriko Oyama-Manabe, MD, PHD,b Toshihisa Anzai, MD, PHDaABSTRACT
We report a case of cardiac lipoma with intramyocardial invasion complicated by visceral inversion, which, to the best of ourknowledge, has not been reported before. Multimodality imaging played an important role in differential diagnosis anddetermination of the management strategy. (Level of Difﬁculty: Advanced.) (J Am Coll Cardiol Case Rep 2020;2:1570–1)© 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is anopen access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

A63-year-old asymptomatic woman with visceral inversion, rheumatoid arthritis, and scleroderma
treated with prednisolone 9 mg/day and methotrexate 16 mg/week was admitted for managementof an intracardiac mass incidentally found on computed tomography (CT). Although visceral inversion

was detected on CT when the patient was in her thirties, the intracardiac mass was not identiﬁed at the time.

On admission, her blood pressure was 124/75 mm Hg and pulse rate 88 beats/min. Clinical examination
revealed no heart murmur. CT revealed a 3-cm low-density mass with mean CT value of -40 HU in the apicalanterior wall of the left ventricle; it inﬁltrated the muscle layer and showed no contrast enhancement(Figure 1A). Echocardiography revealed protrusion of a slightly mobile mass into the left ventricular (LV) cavity(Video 1). Although thrombosis after myocardial infarction must be considered for a mass in the LV apex, LV
wall motion did not suggest myocardial infarction. 18F-ﬂuoro-deoxyglucose positron emission tomography–CT showed no signiﬁcant focal uptake in the mass (Figure 1B), suggesting low probability of malignancy. Cardiac magnetic resonance imaging (MRI) showed a high intensity on T1- and T2-weighted images with fat suppression without contrast enhancement (Figure 1C to 1F, Videos 2 and 3). Based on these ﬁndings, benign
cardiac lipoma was suspected. Owing to the high surgical risk for histological diagnosis and absence oftumor-related symptoms, careful follow-up was planned. Follow-up CT after 6 months showed no change inthe size of the mass and no tumor-associated symptoms on follow-up for 9 months.
Cardiac lipomas represent 8.4% of primary cardiac tumors (1), most commonly originating in the subendocardium (50%), followed by the myocardium (25%) and subepicardium (25%); typical locations include theright atrium and the left ventricle (1). The degree of symptoms depends on the location and size of the tumors.
Notably, cardiac lipoma complicating visceral inversion has never been reported. Visceral inversion is associated with genetic mechanisms but not with the development of cardiac tumors (2). Despite reports of concurrent development of visceral inversion and digestive system neoplasms, the presence of cardiac lipoma andvisceral inversion could be incidental. Accordingly, the clinical manifestation of this case is rare.

From the aDepartment of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University,
Sapporo, Japan; and the bDepartment of Radiology, Saitama Medical Center, Jichi Medical University, Omiya, Japan. All authors
have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the JACC: Case Reports author instructions page.
Manuscript received March 18, 2020; revised manuscript received May 13, 2020, accepted May 26, 2020.

ISSN 2666-0849

https://doi.org/10.1016/j.jaccas.2020.05.061

Kadosaka et al.

JACC: CASE REPORTS, VOL. 2, NO. 10, 2020
AUGUST 2020:1570–1

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Invasive Cardiac Lipoma

Recent advances in cardiac imaging have enabled accurate diagnosis of cardiac

ABBREVIATIONStumors (3) although it must be conﬁrmed based on pathological ﬁndings. Surgical

AND ACRONYMS

resection is the standard management of benign cardiac tumors to relieve tumorassociated symptoms or reduce the risk of embolic events. However, managementof asymptomatic patients as in this case remains unstandardized and is based on therisk of invasive strategy. In LV lipomas with invasion into the myocardium, surgicalresection is unsafe owing to surgical complications such as intraoperative cardiac

CT = computed tomography
LV = left ventricular
MRI = magnetic resonanceimaging

rupture, coronary artery injury, and postoperative lethal arrhythmias (3). Our case was complicated withconnective tissue disease requiring immunosuppressive therapy, which also increased the perioperative risk ofcomplications, resulting in careful follow-up without surgical resection.
In conclusion, we report the ﬁrst case of cardiac lipoma with intramyocardial invasion complicating visceralinversion. Multiple imaging enabled noninvasive differential diagnosis and management of the cardiac tumor.
ADDRESS FOR CORRESPONDENCE: Dr. Shingo Tsujinaga, Department of Cardiovascular Medicine, Faculty ofMedicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638,
Japan. E-mail: shingo-t.0207@med.hokudai.ac.jp.

F I G U R E 1 Multimodality Imaging of Invasive Cardiac Lipoma Complicating Visceral Inversion

The red star shows the left ventricle, whereas the yellow star shows the right ventricle. (A) Contrast-enhanced CT demonstrates a 29  27 mm low-density mass(mean CT value of -40 HU) in the anterior wall of the apical left ventricle (A, light blue arrow), which shows no contrast enhancement. The anatomy indicates visceralinversion. (B) 18F-ﬂuoro-deoxyglucose positron emission tomography–CT shows no focal uptake in the intracardiac mass (B, light blue arrow). (C and D) Cardiac MRIshows a high intensity in the mass on both of T1WI (C, light blue arrow) and T2WI (D, light blue arrow). (E) The high intensity of the mass was suppressed in the fatsuppressed T1WI (E, light blue arrow). (F) Gadolinium-enhanced T1WI shows no contrast effect in the mass (F, light blue arrow). CT ¼ computed tomography; MRI ¼magnetic resonance imaging; T1W1 ¼ T1-weighted image.

REFERENCES
1. D’Souza J, Shah R, Abbass A, Burt JR, Goud A,Dahagam C. Invasive cardiac lipoma: a case report andreview of literature. BMC Cardiovasc Disord 2017;17:28.
2. Peeters H, Devriendt K. Human laterality disorders. Eur J Med Genet 2006;49:349–62.
3. Sun X, Liu G, Kim H, Sun W. Left ventricularlipoma resected using thoracoscope-assisted

limited sternotomy: a case report and literature review. Medicine (Baltimore) 2018;97:e11436.

KEY WORDS cardiac lipoma,intramyocardial left ventricular lipoma,visceral inversion

A PP END IX For supplemental videos,please see the online version of this paper.