Cardiac hemangiomas represent only 1–2% of all benign heart tumors [1]. Most affected patients are asymptomatic, but symptoms that do occur depend on the tumor’s location and size and are always non-specific, such as dyspnea, arrhythmia, angina, signs of right heart failure, and thromboembolic events [4, 5]. Consequently, cardiac hemangiomas are often discovered by transthoracic echocardiography and misdiagnosed as other cardiac neoplasms (e.g., cardiac myxoma) [6]. The right ventricular hemangioma is extremely rare, especially at the apex of the RV. According to Jiang et al. [3], the most common site of right ventricular hemangiomas is the anterior wall of the RV, but only 6.7% are located at the apex of the RV. In our case, the hemangioma was located at the apex of the RV and grew outward reaching 4.0 cm, which was different from most cardiac hemangiomas, which were single, relatively small subendocardial nodules (2.0–3.5 cm) [7]. These characteristics significantly increased the difficulty of diagnosis.

Diagnostic tools for cardiac tumors mainly include echocardiography, chest computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. Transthoracic echocardiography is the preferred diagnostic tool for cardiac tumors because of its non-invasiveness and convenience; however, it cannot accurately distinguish the tissue level and it cannot display the blood supply to the tumor unless contrast-enhanced ultrasound is applied. Considering that there was no obvious blood flow signal in the mass on echocardiography, we deemed it to be of non-cardiac origin preoperatively. Contrast-enhanced CT may compensate for these shortcomings, but it is unfavorable to patients who are allergic to contrast agents or with renal insufficiency.

Coronary CTA and coronary angiography are also used to show the distribution of vessels, feeding vessels to the tumor, and whether the coronary arteries are oppressed [8]. In our case, the origin of the tumor remained a mystery in the result of two coronary CTA images associated with key information of the origin, revealing quite different findings, leaving us in a diagnostic dilemma. If we used CMR at that time, we might determine the properties of the tumor and its relationship with the RV anterior free wall and pericardium. The excellent contrast resolution and multiplanar capability of CMR imaging allows for qualitative diagnosis and optimal anatomical evaluation of any cardiac tumor. In addition, CMR imaging enabled us to demonstrate the precise relationship among the tumor, tricuspid valve, and RV anterior free wall, which is useful for pre-surgical planning [5]. However, the implantation of pacemakers or metal objects, such as biliary stents, and the high price limit the application of CMR in our country.

Surgical removal is the first choice of treatment for cardiac hemangiomas [9]. After complete resection, the prognosis is generally favorable, with a low recurrence rate. Furthermore, an incomplete resection has been reported to produce long-term survival benefits [4].

In our case, since the hemangioma at the apex of the RV is extremely rare, and its diagnosis is difficult, we could not determine the properties of the tumor using echocardiography and CT investigations. CMR should be the ultimate method when diagnosing cardiac tumors that are difficult to be determined. The patient in this case was successfully operated, and there was no recurrence or other complications in the subsequent follow-up.

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