Application of Multimodal Contrast-Enhanced Ultrasound in the Full-Cycle Management of Infant Cardiac Fibroma: A Case Report and Literature Review

Application of Multimodal Contrast-Enhanced Ultrasound in the Full-Cycle Management of Infant Cardiac Fibroma: A Case Report and Literature Review | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 24 March 2025 V1 Latest version Share on Application of Multimodal Contrast-Enhanced Ultrasound in the Full-Cycle Management of Infant Cardiac Fibroma: A Case Report and Literature Review Authors : Zehang Hu 0009-0003-5168-748X , Jin Yu , and Jingjing Ye [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174282698.83349022/v1 169 views 156 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Infant cardiac fibroma is a rare but life-threatening condition, characterized by anatomical complexity and postoperative recurrence risks, posing significant challenges in clinical management. This article presents a case of a 3-month-old male infant managed with multimodal contrast-enhanced ultrasound (CEUS) combined with transthoracic echocardiography (TTE), enabling precise preoperative assessment, real-time intraoperative navigation, and dynamic postoperative surveillance. CEUS effectively identified tumor microcirculation patterns, guided subtotal resection decisions, and facilitated early detection of residual lesions and cardiac dysfunction. Supported by a review of recent literature, this case highlights the innovative role of CEUS in infant cardiac tumor management. Introduction Cardiac fibromas account for 15%–20% of primary pediatric cardiac tumors, predominantly arising in the left ventricle（LV） and interventricular septum with infiltrative growth patterns [1]. Although complete surgical resection remains the gold standard, approximately 20% of cases involve anatomically challenging locations, leading to incomplete resection and increased risks of recurrence and arrhythmias [2]. Traditional imaging modalities, such as cardiac magnetic resonance imaging (CMR), provide high-resolution anatomical details but are limited in neonates due to sedation requirements and accessibility [3]. In contrast, TTE combined with CEUS has emerged as a noninvasive, real-time, and dynamic imaging tool, endorsed by the 2023 AHA/ACC guidelines for pediatric cardiac tumor follow-up [4]. Recent studies demonstrate that CEUS, via microbubble tracing, sensitively characterizes tumor microcirculation and detects subclinical cardiac dysfunction earlier than conventional ejection fraction (EF) measurements [5]. Case Report A male infant, prenatally diagnosed via ultrasound at 36 weeks gestational age with a heterogeneous mass (26×18×17 mm) in the LV. First admitted on day 1 after birth imaging findings: 1) TTE (day 1 of admission): Tumor size increased to 33×30×26 mm. CEUS revealed rich perfusion at the apical and mid-portions of the lesion, abnormal motion of the LV lateral wall, and EF 59%. No inflow or outflow tract obstruction was observed. (Fig. 1). 2) CT angiography (day 2 of admission): Mildly enhancing mass (36×32×25 mm), consistent with rhabdomyoma. 3) CMR (day 7 of admission): Lesion showed long T1/T2 signals (32×24 mm, Fig. 2), suggestive of rhabdomyoma. Following multidisciplinary consultation to assess surgical risks, the infant was discharged for outpatient follow-up. Readmission 3 months later: Physical examination: BP 70/42 mmHg, HR 138 bpm, and a grade II–III systolic murmur at the left sternal border. Laboratory tests: Elevated cardiac biomarkers: CK-MB >80 ng/mL, NT-proBNP 6747.7 pg/mL, troponin I >30.0 ng/mL, myoglobin 271.9 ng/mL, D-dimer 1.21 mg/L. Electrocardiogram (day 1 of admission): Sinus rhythm, abnormal Q waves in high lateral leads, biventricular hypertrophy, and T-wave changes. Imaging Findings (day 1 of admission): 1) TTE: Revealed a large mass (57×53×46 mm) in the LV wall involving the mid to basal segments of the anteroseptal, anterior, lateral, and partial posterior walls. The lesion demonstrated well-defined borders with heterogeneous internal echogenicity, accompanied by LV inflow and outflow tract obstruction. 2) CEUS: The hypoechoic LV wall mass exhibited hypoenhanced perfusion compared to the adjacent myocardium. Myocardial perfusion was preserved with a LV EF of 48%. Concurrent left and right ventricular outflow tract obstructions were observed with peak velocities of 2.0 m/s and 2.1 m/s, respectively (Fig. 3). Treatment process: The child underwent subtotal resection of the LV tumor under extracorporeal circulation on the 30th day post-admission. During the procedure, TTE was utilized to confirm the resection margins in real-time. It was observed that the tumor involved the posterior wall, free wall of the LV, and a portion of the interventricular septum, with proximity to the LV outflow tract. Postoperative management included ECMO support, delayed sternal closure, epicardial pacing, and mechanical ventilation. Histopathology confirmed a spindle cell tumor with invasive margins, consistent with fibroma. Postoperative management: 1) Hemodynamic support: Maintain the mean arterial pressure between 40-64 mmHg with ECMO assistance, the pacing heart rate at 128–163 bpm, and the central venous pressure (CVP) at 17 cmH₂O. 2) Pharmacological treatment: Administer a combination of epinephrine (0.15 μg/kg/min), dopamine (4 μg/kg/min), milrinone (0.5 μg/kg/min), and nitroglycerin (1 μg/kg/min) to stabilize circulation; dexamethasone and ulinastatin to mitigate myocardial inflammatory response; 3) Infection prophylaxis: Cefoperazone-sulbactam (0.35 g q8h) and vancomycin (70 mg q8h). Follow-up：CEUS on postoperative day 10 revealed severe LV dysfunction (EF 28%) and residual hyperperfused tumor at the basal and mid-lateral wall. Multidisciplinary evaluation deemed the prognosis poor, and palliative care was chosen. EF declined to 20% prior to withdrawal of life support. Discussion Primary cardiac tumors in infant are rare, with benign lesions (e.g., rhabdomyoma and fibroma) predominating [6,7]. Fibromas are typically solitary (85%), infiltrative, and associated with complications such as outflow tract obstruction and arrhythmias [6]. While complete resection achieves a 92% cure rate [6], residual lesions necessitate long-term surveillance. MRI, despite its diagnostic utility, is impractical in neonates due to sedation needs [8,9]. TTE, recommended by major guidelines, offers dynamic anatomical and hemodynamic assessment [4]. CEUS further enhances diagnostic precision by delineating microcirculation patterns, differentiating benign (delayed stippled perfusion) from malignant (early diffuse enhancement) lesions [10]. This study demonstrates the application of CEUS in the integrated management of cardiac fibroma throughout its treatment cycle: 1) CEUS discriminates tumor nature through microcirculation features (notably early-phase hyperenhancement) and quantitatively analyzes the severity of hemodynamic obstruction in ventricular inflow/outflow tracts, providing critical imaging evidence for formulating personalized surgical strategies. 2) Intraoperative navigation: Combined with transesophageal echocardiography, CEUS enabled real-time assessment of resection margins, minimizing iatrogenic myocardial injury through precise intraoperative visualization. 3) Postoperative surveillance: CEUS dynamically monitored hemodynamic changes in residual lesions, addressing the limited sensitivity of TTE for micro-lesions. Moreover, CEUS demonstrated superior sensitivity to conventional LVEF measurements in detecting subclinical cardiac dysfunction. In the presented case, CEUS identified early postoperative EF reduction preceding clinical symptom onset, providing critical guidance for timely therapeutic intervention. Conclusion Multimodal CEUS demonstrates significant clinical value in infant cardiac fibroma management, particularly in residual lesion identification and cardiac function surveillance. Its noninvasive nature and reproducibility support broader applications in pediatric cardiology. Multicenter studies are warranted to standardize protocols and validate prognostic models. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Z.H.，Jin.Y.，and J.Y. The first draft of the manuscript was written by Z.H and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding This study was supported by the Key Research and Development Program of Zhejiang Province(2022C03111). Data Availability No datasets were generated or analysed during the current study. Declarations Conflict of interest The authors have no relevant financial or non-financial interests to disclose. References 1. Isaacs H Jr. Fetal and neonatal cardiac tumors. Pediatr Cardiol. 2004;25(3):252-273. 2. Padalino MA, Reffo E, Cerutti A, et al. Medical and surgical management of primary cardiac tumours in infants and children. Cardiol Young. 2014;24(2):268-274. 3. Inserra MC, Cannizzaro MT, Passaniti G, et al. MR imaging of primary benign cardiac tumors in the pediatric population. Heliyon. 2023;9(9):e19932. 4. Miller TE et al. 2023 AHA/ACC guideline for the management of cardiac tumors. J Am Coll Cardiol. 81(15): e235-e282 . 5. Zhan J, Zhong L, Wu J. Assessment and Treatment for Coronary Microvascular Dysfunction by Contrast Enhanced Ultrasound. Front Cardiovasc Med. 2022;9:899099. 6. Shi L, Wu L, Fang H, et al. Identification and clinical course of 166 pediatric cardiac tumors. Eur J Pediatr. 2017;176(2):253-260. 7. Bielefeld KJ, Moller JH. Cardiac tumors in infants and children: study of 120 operated patients. Pediatr Cardiol. 2013;34(1):125-128. 8. Lin Y, Xie M, Qian M, Gao L, Ji MM, Li Y. Cardiac fibroma: characteristics on echocardiography and cardiac magnetic resonance imaging. QJM. 2022;115(6):412-414. 9. Flores C, Lundberg J, Richardson RR, Prasad D. Utility of cardiac imaging in diagnosis of atypical presentation of cardiac fibroma. BMJ Case Rep. 2019;12(9):e230333. 10. Fang C, Anupindi SA, Back SJ, et al. Contrast-enhanced ultrasound of benign and malignant liver lesions in children. Pediatr Radiol. 2021;51(12):2181-2197. Fig. 1 One day postpartum: A The subxiphoid view of echocardiography reveals a mass within the left ventricle, measuring approximately 36 mm × 32 mm×26 mm. B Contrast-enhanced ultrasound demonstrates relatively abundant perfusion within the mass, predominantly localized to the apical and mid-ventricular segments. Fig. 2 7 days postpartum: Cardiac magnetic resonance (CMR) imaging confirms the presence of an intra-left ventricular mass. Fig.3 Three months postpartum: A Echocardiography indicates the presence of a mass in the left ventricle, now measuring approximately 57 mm × 53 mm × 46 mm. B Contrast-enhanced ultrasound shows that perfusion within the mass has become less dense compared to the initial observation, with evidence of left ventricular inflow and outflow tract obstruction. Information & Authors Information Version history V1 Version 1 24 March 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords cardiac fibroma case report contrast-enhanced ultrasound full-cycle management infant Authors Affiliations Zehang Hu 0009-0003-5168-748X Zhejiang University School of Medicine Children's Hospital National Clinical Research Center for Child Health View all articles by this author Jin Yu Zhejiang University School of Medicine Children's Hospital National Clinical Research Center for Child Health View all articles by this author Jingjing Ye [email protected] Zhejiang University School of Medicine Children's Hospital National Clinical Research Center for Child Health View all articles by this author Metrics & Citations Metrics Article Usage 169 views 156 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Zehang Hu, Jin Yu, Jingjing Ye. Application of Multimodal Contrast-Enhanced Ultrasound in the Full-Cycle Management of Infant Cardiac Fibroma: A Case Report and Literature Review. Authorea . 24 March 2025. 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