Rare finding of a pericardial lipoma in a pediatric

patient presenting with ventricular tachycardia

Majid Husain, MD,*† Anthony McCanta, MD, FHRS,*† Anjan S. Batra, MD, MBA, FHRS*†
From the *Children’s Hospital of Orange County, Orange, California, and †UC Irvine Health School of
Medicine, Irvine, California.

Introduction KEY TEACHING POINTS

Primary cardiac lipomas in children are rare and often re-
ported as incidental findings during operations or autopsies.  Clinicians must consider primary pericardial tumors
Ventricular tachycardia (VT) is an unusual complication of in the differential diagnosis when evaluating for
primary cardiac lipomas. We describe the case of a 14- unidentifiable sources of arrhythmia or nonspecific
year-old previously healthy male subject who presented cardiac symptoms.
with an idiopathic VT arising from the left ventricle, ulti-
 Echocardiograms focused on intracardiac anatomy
mately diagnosed with a rare pericardial lipoma.
can potentially miss tumors in the extracardiac
space. Cardiac computed tomography or magnetic
Case report resonance imaging is the modality of choice for
A 14-year-old previously healthy male subject, with no sig- evaluation of cardiac masses.
nificant personal or familial cardiac history, presented to
the emergency room with syncope and several episodes of  Surgical resection of the identified mass is often
a “racing heartbeat” associated with weakness, dizziness, curative.
and sweating. An electrocardiogram (ECG) revealed a mono-
morphic wide complex tachycardia with a right bundle
branch block (RBBB) at 195 beats/min that was unrespon- lesion, likely a pericardial lipoma, that was abutting the infe-
sive to intravenous (IV) amiodarone but terminated with IV rior LV wall, causing irregularity and mass effect upon the
verapamil (Figure 1). The QRS duration in VT varied from cardiac apex. Cardiac magnetic resonance imaging found
180 ms to 200 ms. A baseline 12-lead ECG after termination the lesion to be most consistent with a lipoma, with fat sup-
of the tachycardia showed sinus rhythm with early repolari- pression best appreciated on the T2-weighted images
zation and T-wave inversion in the inferior and lateral precor- (Figure 3).
dial leads (Figure 2). The initial echocardiogram showed He underwent resection of a majority of the cardiac tumor
normal function and no intracardiac abnormalities. with primary reconstruction of the left ventricle via a midline
A stress test showed no arrhythmias with exercise and a sternotomy. Pathology of this mass revealed homogeneous,
24-hour Holter monitor showed monomorphic premature yellow adipose tissue throughout, consistent with a lipoma.
ventricular contractions ,1%. An electrophysiologic study He had an uneventful postoperative course and there were
failed to induce or detect the origin of the arrhythmia. How- no additional arrhythmias noted. He was discharged in stable
ever, the patient had recurrent episodes of VT that terminated condition after a 13-day hospitalization. He has remained
acutely with IV verapamil. asymptomatic, with no arrhythmias on serial Holter monitors
A repeat echocardiogram with visualization of the pericar- for 2 years.
dial area beyond the left ventricular (LV) apex revealed an
echogenic density in the epicardium suspicious of a tumor
impinging on the LV apex and lateral wall. Subsequent car- Discussion
diac computed tomography characterized the above-stated Wide complex monomorphic tachycardias, in the absence of
echogenic density as a 6.3 ! 3.7-cm ill-defined fat-density structural heart disease, arise most commonly from the right
ventricle (75%–90%) and less commonly (10%–15%) from
the left ventricle. The most common type of idiopathic VT
KEYWORDS Lipoma; Left ventricle; Pediatric; Pericardial; Ventricular tachy-
cardia
arising from the left ventricle is fascicular VT with
(Heart Rhythm Case Reports 2019;5:277–280) RBBB.1,2 Very rarely, such a tachycardia can be from
Address reprint requests and correspondence: Dr Anjan S. Batra, Chil-
other causes such as a primary cardiac neoplasm.
dren’s Hospital of Orange County, 1140 W La Veta Ave, Suite 750, Orange, Primary cardiac neoplasms, including pericardial lipomas,
CA 92868. E-mail address: abatra@uci.edu. are an exceedingly rare finding and occur with a frequency of

2214-0271/© 2019 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article https://doi.org/10.1016/j.hrcr.2019.02.005
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
278 Heart Rhythm Case Reports, Vol 5, No 5, May 2019

Figure 1 Initial electrocardiogram showing monomorphic wide complex tachycardia with a right bundle branch block and left anterior hemiblock at 195
beats/min. The QRS duration in ventricular tachycardia varied from 180 ms to 200 ms.

Figure 2 Baseline 12-lead electrocardiogram after termination of the tachycardia showed sinus rhythm with early repolarization and T-wave inversion in the
inferior and lateral precordial leads.
Husain et al Pericardial Lipoma in a Patient With Ventricular Tachycardia 279

Figure 3 A, B: Cardiac computed tomography demonstrating the echogenic density as a 6.3 ! 3.7-cm ill-defined fat-density lesion, likely a pericardial and less
likely intracardial lipoma, owing to internal minimal stranding and septation, noted to be abutting the inferior left ventricular wall and causing irregularity and
mass effect upon the cardiac apex. C, D: Cardiac magnetic resonance imaging showing the lesion to be most consistent with a lipoma, with fat suppression best
appreciated on the T2-weighted images.

0.03%–0.32% in the general pediatric population.3–5 While who was found to have a lipoma embedded in the myocar-
most of these neoplasms are typically benign and dium, adjacent to but not involving the circumflex coronary
asymptomatic, their association with clinically significant artery.11
arrhythmias has been previously reported. Notably, in one From a diagnostic perspective, echocardiograms focused
of the largest studies of pediatric primary cardiac tumors on intracardiac anatomy can potentially miss tumors in the
(n 5 173), clinically significant arrhythmias were reported extracardiac space, as was seen on the initial echocardiogram
to occur in 42 (24%) of the cases—consisting of in our case. Cardiac computed tomography or magnetic reso-
rhabdomyomas, fibromas, myxomas, and teratomas. nance imaging is the modality of choice for evaluation of car-
Lipomas made up a minority of the total cases (n 5 3, diac masses. This also provides necessary information on
1.7%) and none of these 3 cases had any arrhythmias, myocardial and pericardial extension, vascularity, and ex-
hemodynamic compromise, or coronary involvement.5 Simi- tracardiac extension.
larly, a recent study of 166 pediatric patients with cardiac tu- From a treatment perspective, it is important to differen-
mors found clinically significant arrhythmias in 11 (6.6%) of tiate a fascicular VT from a VT originating from the myocar-
the cases. Rhabdomyomas and fibromas made up the major- dium in the left ventricle. While the ECG during both
ity of these cases. There were a total of 5 cases of lipomas tachycardias can be characterized by RBBB with a left supe-
identified; none was associated with an arrhythmia.6 Further- rior axis, suggesting an exit site from the inferoposterior ven-
more, Beghetti and colleagues7 had previously identified 56 tricular septum, the QRS duration in fascicular VT varies
pediatric patients with various cardiac tumors and described from 140 ms to 150 ms and the rates are relatively slower.
arrhythmias in 11 cases. Again, rhabdomyomas and fibromas As was seen in our case, calcium channel blockers may be
were the common culprit. The 1 reported case of an epicardial effective in terminating both tachycardias and cannot be
lipoma was not associated with an arrhythmia.7 Data used to differentiate the 2 forms of tachycardia.
regarding the association of a pericardial lipoma with clini- The mechanism of VT in our patient was likely triggered
cally significant arrhythmias have been largely limited to a by automaticity vs reentry. Clinical observation from our
few case reports.8–11 We found only 1 pediatric case report case suggests that calcium channel blockers may be effec-
of a previously healthy 13-year-old male patient with VT tive in suppressing the ventricular arrhythmias and supports
280 Heart Rhythm Case Reports, Vol 5, No 5, May 2019

the previously well-established experiences that surgical 3. Restrepo CS, Vargas D, Ocazionez D, Martínez-Jiménez S, Betancourt
Cuellar SL, Gutierrez FR. Primary pericardial tumors. RadioGraphics 2013;
resection can be an effective, sometimes curative, option 33:1613–1630.
for the elimination of life-threatening and difficult-to- 4. Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996;77:107.
control arrhythmias caused by primary cardiac/pericardial 5. Miyake CY, Del Nido PJ, Alexander ME, et al. Cardiac tumors and associated
arrhythmias in pediatric patients, with observations on surgical therapy for ven-
tumors.5 tricular tachycardia. J Am Coll Cardiol 2011;58:1903–1909.
6. Shi L, Wu L, Fang H, et al. Identification and clinical course of 166 pediatric car-
diac tumors. Eur J Pediatr 2017;176:253–260.
Conclusion 7. Beghetti M, Gow RM, Haney I, Mawson J, Williams WG, Freedom RM. Pediat-
Pericardial neoplasms should remain on the differential diag- ric primary benign cardiac tumors: a 15-year review. Am Heart J 1997;
134:1107–1114.
nosis when evaluating for unidentifiable sources of 8. Shenthar J, Sharma R, Rai MK, Simha P. Infiltrating cardiac lipoma present-
arrhythmia or nonspecific cardiac symptoms—especially ing as ventricular tachycardia in a young adult. Indian Heart J 2015;
when refractory to standard treatments. 67:359–361.
9. Fukushima KK, Mitani T, Hashimoto K, et al. Ventricular tachycardia in a patient
with cardiac lipoma. J Cardiovasc Electrophysiol 1999;10:1161.
10. Qi L, Yang Y, Huo Y, Sun JP. Cardiac lipoma with ventricular arrhythmias. In:
References Sun JP, Yang XS, Yan BP, eds. Comparative Cardiac Imaging: A Case-based
1. Quimby TW, Clark AA, Fix ML. Idiopathic ventricular tachycardia: Belhassen Guide. Hoboken, NJ: Wiley; 2018:197–200.
type. West J Emerg Med 2010;11:389–390. 11. Friedberg MK, Chang IL, Silverman NH, Ramamoorthy C, Chan FP. Images in
2. Chiu C, Sequeira IB. Diagnosis and treatment of idiopathic ventricular tachy- cardiovascular medicine. Near sudden death from cardiac lipoma in an adolescent.
cardia. AACN Clin Issues 2004;15:449–461. Circulation 2006;113:778–779.