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.