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\begin{document}

\title{Don't Forget the Cardiac Fibroma: Coronavirus Disease 2019 and the
Management of Patient with a Large Cardiac Fibroma}



\author[1]{Weston Andrews}%
\author[2]{Thomas  Moon}%
\author[3]{Sunita Ferns}%
\author[3]{Jeremy Gebhardt}%
\author[3]{Kara Blackmer}%
\author[4]{Harma Turbendian}%
\author[4]{Michael Shillingford}%
\affil[1]{University of Florida Health at Jacksonville}%
\affil[2]{Division of Pediatric Cardiology, University of Florida College of Medicine}%
\affil[3]{Wolfson Children’s Hospital, Baptist Medical Center}%
\affil[4]{Wolfson Children’s Hospital, University of Pittsburgh Medical Center}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
COVID-19 has introduced a monumental challenge to the routine delivery
of healthcare and protection of healthcare professionals. Conditions
that are life threatening and need urgent intervention add another layer
of complexity. This brief report reviews the management of a large
cardiac fibroma found in the setting of COVID-19.%
\end{abstract}%



\sloppy


\textbf{Don't Forget the Cardiac Fibroma: Coronavirus Disease 2019 and
the Management of Patient with a Large Cardiac Fibroma}

Weston G. Andrews MD*, Thomas Moon MD**, Sunita Ferns MD***, Jeremy
Gebhardt PA-C***, Kara Blackmer PA-C***, Harma K.Turbendian MD****,
Michael Shillingford MD****

*Department of Surgery, University of Florida College of Medicine,
Jacksonville, Florida

**Department of Pediatrics, Division of Pediatric Cardiology, University
of Florida College of Medicine, Jacksonville, Florida

*** Wolfson Children's Hospital, Baptist Medical Center, Jacksonville,
Florida

**** Wolfson Children's Hospital, University of Pittsburgh Medical
Center, Jacksonville, Florida

\textbf{Running Title:} Covid-19 and a Pediatric Cardiac Fibroma

\textbf{Corresponding Author:}

Weston G. Andrews (ORCID: 0000-0003-3709-6838)

Department of Surgery UF College of Medicine -- Jacksonville 653 West
8th Street, FC12 3rd Floor, Faculty Clinic Jacksonville, FL 32209

(904) 962-2236

Weston.andrews@jax.ufl.edu

\textbf{Key Words:} pediatric cardiac surgery, cardiac tumors, SARS CoV2

\textbf{Conflicts of Interest:} None

\textbf{Source of Funding} : None

\textbf{Abstract}

COVID-19 has introduced a monumental challenge to the routine delivery
of healthcare and protection of healthcare professionals. Conditions
that are life threatening and need urgent intervention add another layer
of complexity. This brief report reviews the management of a large
cardiac fibroma found in the setting of COVID-19.

\textbf{Abbreviations:}

Coronavirus disease 2019 (COVID-19)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2)

Electrocardiogram (ECG)

\textbf{Introduction}

The coronavirus disease-2019 (COVID-19) pandemic has had an
unprecedented impact on patients and patient care management worldwide,
including the field of congenital cardiology and cardiac
surgery.\textsuperscript{1} Traditional management algorithms are
challenged by the unpredictable nature of COVID-19. This case report
highlights an important, treatable diagnosis complicated by a
concomitant COVID-19 infection.

Primary cardiac tumors in children are extremely
rare.\textsuperscript{2--4} Most tumors are reported as case reports or
as single institution case series. These are usually benign, and the
most common pathology in the pediatric population is the rhabdomyoma,
followed by fibromas, myxomas, teratomas, and hemangiomas. Up to 12\%
will be found incidentally but the rate of growth, location, and size of
the tumor determines the clinical presentation.\textsuperscript{5} Most
children will present with a one or more of the following symptoms:
murmur, arrhythmia, cyanosis, dyspnea, or cardiac
failure.\textsuperscript{6} Surgical resection remains the standard of
care for primary cardiac tumors in children. Echocardiography and
magnetic resonance imaging are the gold standard for diagnosing cardiac
tumors; computed tomography can be a useful adjunct.

Pediatric cardiac fibromas most often arise from the left
ventricle.\textsuperscript{7} Noninvasive, fibromas of the heart can
exert pressure on vital parts of the heart including the coronary
arteries and valves. A multicenter European study of pediatric primary
cardiac tumors reported a 10\% rate of arrhythmias associated with
cardiac fibromas and a 20\% overall rate of arrhythmias associated with
all cardiac tumors.\textsuperscript{2} These rhythm disturbances were
most often ectopic atrial or ventricular beats, followed by atrial
flutter and paroxysmal supraventricular tachycardia. Due to the
association with sudden cardiac death, pediatric cardiac fibromas are
typically resected even in asymptomatic patients.\textsuperscript{8} We
report a pediatric case of cardiac fibroma in a child who was diagnosed
with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on a
pre-operative work-up. No institutional review, consent, or clinical
trial registration was required for this case report and review.

\textbf{Case Report}

A 4-year-old male with no significant past medical history presented to
his pediatrician for a routine well-child visit and was noted to be in
tachycardia at over 250 beats per minute. Further questioning revealed
he had been experiencing some nausea and vomiting a few days prior to
presentation but was otherwise asymptomatic. He was sent to the
emergency room where an electrocardiogram (ECG) demonstrated a wide
complex tachycardia at a rate of 270 bpm (Figure 1). He received three
escalating doses of adenosine with no effect, followed by amiodarone
(5mg/kg) intravenously with some rate but no rhythm control. He was then
sedated and successfully cardioverted to a normal sinus rhythm. A chest
radiograph showed a cardiac silhouette that appeared enlarged (Figure 2)
and he was admitted for further management. Lab work was remarkable for
a hemoglobin of 10.9 g/dL, brain natriuretic peptide (BNP) of 998 pg/mL,
C reactive protein of 3.8 mg/dL, and a troponin of 0.21 ng/mL. The viral
panel was positive for Epstein Barr Virus and Human Rhinovirus at
presentation and was initially negative for the SARS CoV2 Rapid PCR
test. A repeat PCR test 48 hours later, however, was positive for SARS
CoV2. Echocardiogram images demonstrated a left ventricular (LV) mass
along the free wall of the left ventricle extending to the apex and a
small pericardial as well as a right pleural effusion. (Figure 3) The
mass was further delineated on a cardiac magnetic resonance imaging scan
that showed a 22x 52 mm mass with a distinct separation between the LV.
The mass presumed to be a fibroma based on MRI characterization. (Figure
4)

He was started on 3 mg/kg/day of propranolol administered TID. He did
not experience any further episodes of ventricular tachycardia and only
had occasional premature ventricular contractions. Serial BNP and
troponin labs began to normalize within 72 hours of admission.
Considering the positive SARS CoV2 PCR test, cardiac surgery for mass
excision was postponed. He was discharged home on a 30-day real-time,
wireless cardiac event monitor that allowed for close monitoring while
awaiting surgery.

Three weeks later he underwent a resection of the cardiac fibroma. The
mass was intimately associated with the distal left anterior descending
artery which was preserved and had limited septum involvement. He was
transferred to the pediatric cardiovascular intensive care unit and had
an uneventful recovery. A post-operative echocardiogram demonstrated
normal biventricular function with no valve regurgitation and no
residual mass or effusion. He was discharged home on post-operative day
5 after an uneventful postoperative course. The propranolol was
eventually discontinued 3 months post-surgery as he continued to
demonstrate no arrhythmias. The final pathology demonstrated a benign
cardiac fibroma with intact borders.

\textbf{Discussion}

Pediatric cardiac fibromas require prompt surgical attention. Due to the
less invasive and benign nature, surgical treatment is considered
relatively safe, with low intraoperative and post-operative morbidity
and mortality rates.\textsuperscript{2,7} The diagnosis itself is an
indication for resection, but may also include the presence of cardiac,
pulmonary, or neurogenic symptoms, abnormal ECG findings, and evidence
of hemodynamic impairment on echocardiogram. The presentation of the
reported cardiac fibroma is not uncommon. A 42-year experience with
pediatric cardiac tumors from Boston Children's Hospital reported that,
compared to other tumors of the heart, fibromas were more likely to
present with clinically significant arrhythmias.\textsuperscript{9} This
patient was successfully stabilized with cardioversion and managed
medically while he was evaluated for surgical resection.
Echocardiography and MRI allowed for the tumor margins and architecture
to be assessed adequately and for a surgical strategy to be planned.

The concurrent diagnosis of COVID-19 added a layer of complexity.
Fortunately, the only side-effect experienced was a delay in definitive
treatment. While this novel virus is known to cause cardiac arrhythmias
in adults, it is difficult to speculate as to whether the virus
precipitated the tachyarrhythmia or whether the tachyarrhythmia
associated with the cardiac fibroma might have occurred independent of
the viral illness.\textsuperscript{10} Once the child was diagnosed with
COVID-19, an alternative plan needed to be fashioned to ensure patient
safety. There are no consensus guidelines for triaging this unique
patient.\textsuperscript{11} The care team prioritized the immediate
risk to his life; the arrhythmia secondary to the cardiac fibroma. Once
stable on medical management, the child then was sent home with close
follow-up to recover from a relative asymptomatic COVID-19 infection.
The patient returned three weeks later with a negative test for COVID-19
and underwent surgical resection.

This case report highlights critical dilemmas faced by the health care
community during this pandemic. How do we care for a patient with a
life-threatening condition that concurrently presents with COVID-19? And
how do we quantify the risk of exposing surgical and medical personnel
to the risk of delaying treatment of a potentially lethal condition? A
case such as this requires a large amount of specialized healthcare
personnel to care for the patient. The risk to healthcare workers is
significant during this pandemic and has the potential to cripple a
congenital cardiac program if one were to contract the virus. On the
other hand, this child experienced a potentially malignant arrhythmia
with a very treatable cause. Treatment decisions, especially in cases
such as this, require a thoughtful risk benefit analysis and consensus
by the entire treatment team. In summery we present the successful
treatment of a pediatric cardiac fibroma in the setting of a COVID-19
diagnosis.

\textbf{Figure 1} : Electrocardiogram at presentation shows a wide
complex tachycardia with atrioventricular dissociation at 270 bpm with a
right bundle branch block pattern, negative complexes in the inferior
leads (II, III and aVF) and left sided leads (I, VL, V4-6) suggesting a
more apical origin near the free wall of the left ventricle.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 2} : Chest radiograph depicting left ventricular free
wall fibroma\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 3} : Echocardiography of left ventricular free wall
fibroma\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 4} : Cardiac magnetic resonance imaging depicting a left
ventricular free wall fibroma\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{References}

1. Protopapas EM, Rito M Lo, Vida VL, et al. Early Impact of the
COVID-19 Pandemic on Congenital Heart Surgery Programs Across the World:
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Congenit Hear Surg} . 2020;11(6):689-696. doi:10.1177/2150135120949462

2. Padalino MA, Vida VL, Boccuzzo G, et al. Surgery for primary cardiac
tumors in children early and late results in a multicenter european
congenital heart surgeons association study. \emph{Circulation} .
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3. Delmo Walter EM, Javier MF, Sander F, Hartmann B, Ekkernkamp A,
Hetzer R. Primary Cardiac Tumors in Infants and Children: Surgical
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2016;102(6):2062-2069. doi:10.1016/j.athoracsur.2016.04.057

4. Ying L, Lin R, Gao Z, Qi J, Zhang Z, Gu W. Primary cardiac tumors in
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5. Reynen K. Cardiac Myxomas. \emph{N Engl J Med} .
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6. Isaacs H. Fetal and neonatal cardiac tumors. \emph{Pediatr Cardiol} .
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7. Cho JM, Danielson GK, Puga FJ, et al. Surgical Resection of
Ventricular Cardiac Fibromas: Early and Late Results. \emph{Ann Thorac
Surg} . 2003;76(6):1929-1934. doi:10.1016/S0003-4975(03)01196-2

8. Cina SJ, Smialek JE, Burke AP, Virmani R, Hutchins GM. Primary
cardiac tumors causing sudden death: A review of the literature.\emph{Am
J Forensic Med Pathol} . 1996;17(4):271-281.
doi:10.1097/00000433-199612000-00001

9. Miyake CY, Del Nido PJ, Alexander ME, et al. Cardiac tumors and
associated arrhythmias in pediatric patients, with observations on
surgical therapy for ventricular tachycardia. \emph{J Am Coll Cardiol} .
2011;58(18):1903-1909. doi:10.1016/j.jacc.2011.08.005

10. Kochi AN, Tagliari AP, Forleo GB, Fassini GM, Tondo C. Cardiac and
arrhythmic complications in patients with COVID-19. \emph{J Cardiovasc
Electrophysiol} . 2020;31(5):1003-1008. doi:10.1111/jce.14479

11. Stephens EH, Dearani JA, Guleserian KJ, et al. COVID-19: Crisis
Management in Congenital Heart Surgery. \emph{Ann Thorac Surg} .
2020;110(2):701-706. doi:10.1016/j.athoracsur.2020.04.001

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