primary cardiac tumors are rare , and hemangiomas are believed to represent 1 - 10% of benign forms .
single casereports are described in literature depicting a heterogeneous pathology with significant clinical differences . due to the rarity and the possibility of a silent clinical course
we hereby report a case of right ventricular silent hemangioma and review our previous experience and literature . from 1998 to 2014four cardiachemangiomas , 9.5% of benign primary cardiac tumors ,
imaging characteristics of hemangiomas on transthoracic and transesophageal echocardiography , cardiac magnetic resonance ( cmr ) , computed tomography ( ct ) , and angiographyare reviewed .
a fixed plurilobulated mass originating from the right ventricular lateral wall was incidentally diagnosed [ video 1 ] .
echogenicity was the same as the myocardium , dimensions 35  28 cm [ figure 1 panel a ] , and neither outflow tract obstruction nor interference with tricuspid valve dynamic was present .
on cmr ; the mass appeared homogeneous , with intermediate - to - high signal on t1-weighted [ figure 1 panel b ] and diffuse hyperintensity on t2-weighted images [ figure 1 panel c ] .
no late gadolinium enhancement was present [ figure 1 panel d ] ; first pass enhancement was late and heterogeneous [ video 2 and figure 2 panel a ] .
ct showed no extracardiac infiltration , the feeding artery was a branch of therightcoronary artery [ figure 2 panel b ] .
( panel a ) transthoracic echocardiographic four - chamber view showing the ovalar isoechoic mass originating from the right ventricular lateral wall and occupying half of the rv cavity .
( panel b ) cardiac magnetic resonance t1-weighted sequence with fat suppression short axis view shows homogeneous , intermediate - to - high signal intensity .
( panel c ) cardiac magnetic resonance t2-weighted sequence four - chamber view shows a diffused hyperintensity .
( panel d ) cardiac magnetic resonance t1-weighted sequence short axis view shows absence of late gadolinium enhancement ( panel a ) cardiac magnetic resonance first pass perfusion imaging showing late and heterogeneous enhancement .
( panel b ) computed tomography modified four - chamber view shows no evidence of pericardial or extracardiac infiltration .
( panel c ) on gross examination , the mass appeared russet - colored , homogeneous , and noncapsulated .
( panel d ) histologic specimen , hematoxylin and eosin , original magnification , 40 : multiple large , thin - walled , dilated vascular spaces ( arrow ) can be seen within the ventricular wall differential diagnosis was between thrombosis and tumor .
a thrombus was unlikely as no signs of right ventricular failure , deep venous thrombosis , or pulmonary embolism were present ; moreover , infiltration of the rv lateral wall was suspected .
mri signal intensity was not typical of thrombosis and imaging characteristics could suggest a myxoma , which seemed the most probable diagnosis before surgical removal .
an endomyocardial biopsy was taken into consideration , but would involve a high embolic and bleeding risk . although asymptomatic , surgical removal was decided in order to avoid embolic risk , hemodynamic consequences , and pericardial infiltration .
on gross examination ; it appeared a solitary russet , homogeneous , noncapsulated mass with dimensions 2.5  2  1 cm ; and it was sessile , mildly polilobated , homogeneous soft in consistence [ figure 2 panel c ] .
the tumor was completely excised with transventricular approach taking care not to damage the right coronary artery branches .
the postoperative course was uneventful and the patient discharged in good condition on postoperative day 4 .
histological examination demonstrated multiple endothelial - lined , large , thin - walled , and dilated vascular channels with interspersed fibrous septa and filled with blood or thrombosis : diagnosis of a cardiac heamngioma of the cavernous type was established .
from 1998 to 2014 , 46 consecutive primary cardiac tumors have been diagnosed in our department .
four hemangiomas have been found , accounting for 8.7% of all primary cardiac tumors and 9.5% of benign forms .
localization was mitral valve in two cases ( one cavernous and one capillary ) , interatrial septum ( arteriovenous type ) in one , and right ventricle ( cavernous type ) in the present case ( one ) .
they were all asymptomatic , incidentally found on routine echocardiographic examination and have been operated on without complications .
cavernous types , characterized by multiple dilated thin - walled vessels , are the most frequent . all ages may be affected and a female predominance is described .
they can involve atria , ventricles , pericardium , and valves ; but no chamber predilection seems to be present . in a review of 56 cases of cardiac hemangiomas , the site of origin was : 36% in the right ventricle , 34% in the left ventricle , 23% in the right atrium , and the rest on the interatrial septum and in the left atrium .
these tumors are slow growing , although a rapid growth has been reported in one case .
transesophageal echocardiography may help in estimation of intra- and extracardiac extension , attachment , presence of intracavitary obstruction , or interference with valvular dynamics .
ct and cmr provide more useful information about the invasiveness of the tumor and extracardiac extent .
cmr demonstrates intermediate signal intensity on t1-weighted and hyperintense on t2-weighted images due to high water content ; on first pass perfusion imaging a rapid and strong fill - in is characteristic , mass  disappearance  in the intracavitary blood pool suggests highly vascular nature .
late gadolinium enhancement is typically absent , although focal areas of fibrosis may be present .
cardiac catheterization demonstrates the blood supply and a tumor blush due to the high vascularity , although sometimes dilated vascular channels cause slow flow and absence of first pass perfusion enhancement .
cardiac hemangiomas are often asymptomatic , but may present with arrhythmias , complete heart block , sudden death , dyspnea , congestive heart failure , outflow tract obstruction , coronary insufficiency , pericardial effusion , and tamponade .
the hemodynamic consequences of unoperated cardiac hemangiomas can not be predicted ; therefore , although spontaneous resolution has been reported , resection is always recommended .
 a 74-year - old man underwent echocardiographic exam for hypertension screening . a fixed plurilobulated mass originating from the right ventricular lateral wall and occupying half of the cavity 
 was incidentally diagnosed . on cardiac magnetic resonance ( cmr ) 
 it appeared homogeneous , intermediate - to - high signal on t1-weighted , and diffusely hyperintense on t2-weighted images . 
 first pass enhancement was late and heterogeneous and no late gadolinium enhancement was present . 
 computed tomography ( ct ) showed no extracardiac infiltration , the feeding artery was a branch of therightcoronary artery . 
 the tumor was excised and histological examination demonstrated a hemangioma of the cavernous type . 
 the postoperative course was uneventful . from 1998 to 2014 
 , four cardiac hemangiomas have been diagnosed in our department , accounting for 8.7% of all primary cardiac tumors and for 9.5% of all benign forms ; estimated population prevalence was 0.11/100.000 inhabitants / year . 
 the hemodynamic consequences of unoperated cardiac hemangiomas can not be predicted and therefore , resection is recommended . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS
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