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.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.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.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.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.
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.