CASE REPORT PATHOLOGY ⁄ BIOLOGY Junaid Patel, 1 M.D. and Mary N. Sheppard, 1 M.D. Sudden Death Owing to Right Atrial Hemangioma* ABSTRACT: Primary cardiac tumors are rare, with an autopsy incidence of 0.03%. Seventy-nine percent to 85% of primary cardiac tumors are benign, and of the benign tumors, cardiac hemangiomas account for 5–10% of cases. Most cardiac hemangiomas are asymptomatic and are discov- ered incidentally at autopsy, or by echocardiography, computerized tomography, or magnetic resonance imaging. We report a case of sudden death owing to cardiac hemangioma in a 22-year-old woman who collapsed while shopping and became unresponsive. The autopsy revealed a hemorrhagic mass on the surface of the right atrium which was infiltrating and replacing the wall of the right atrium; histopathological examination confirmed the tumor was a cavernous hemangioma. Fewer than 20 cases of right atrial cavernous hemangiomas have been reported in English literature, emphasiz- ing the rarity of our case. KEYWORDS: forensic science, tumor, hemangioma, sudden death Primary cardiac tumors are rare, with an autopsy incidence of 0.03% (1). Seventy-nine percent to 85% of primary cardiac tumors are benign, and of the benign tumors, cardiac hemangiomas account for 5–10% of cases (2). Hemangiomas consist of benign proliferations of endothelial cells usually forming channels contain- ing blood. Most cardiac hemangiomas are asymptomatic and are discovered incidentally at autopsy, or by echocardiography, com- puterized tomography (CT), or magnetic resonance imaging (MRI). We report a case of right atrial cavernous hemangioma found at autopsy in a 22-year-old woman. Case A 22-year-old lady collapsed while shopping and became unre- sponsive. In the accident and emergency (A&E) department, her Glasgow Coma Scale was 3 ⁄ 15, cardiopulmonary resuscitation was unsuccessful, and the patient was confirmed dead. The patient had presented to A&E a month earlier with shortness of breath and chest pain. She had no other past medical history but did have breast augmentation surgery 4 weeks prior to her death. At autopsy, macroscopic examination revealed a hemorrhagic mass 15 · 10 mm on the surface of the right atrium which was infiltrating and replacing the wall of the right atrium (Fig. 1). This formed rounded blue-colored masses 20 · 15 mm (in total), in the subendocardium of the right atrium encircling the wall which was fragmented. It also involved the right atrial appendage. There was extensive hemorrhage within the mass. The mass infiltrated as far as the atrioventricular junction but did not appear to involve the right coronary artery or right ventricle. The sinoatrial node area could not be identified. Microscopic examination of the right ventricle showed a hemor- rhagic mass consisting of dilated vascular channels lined by flat cells and other more solid areas with admixed red blood cells (Fig. 2a,b). The mass infiltrated and destroyed the right atrial wall, replacing it by tumor. The cells did not look malignant with no mitoses, but there was extensive hemorrhage. The sinoatrial and atrioventricular node could not be identified. These findings were consistent with sudden cardiac death owing to an infiltrating hemangioma of the right atrium destroying the wall and leading to fatal arrhythmia. Discussion Cardiac hemangiomas are rare benign vascular tumors of the heart, with fewer than 50 surgically treated cases reported in the FIG. 1—Mass 15 · 10 mm on the surface of the right atrium infiltrating and replacing the wall of the right atrium. 1 CRY Centre for Cardiac Pathology, National Heart and Lung Institute, Imperial College, London, U.K. *Supported by a grant from Cardiac Risk in the Young, U.K. Received 27 Nov. 2009; and in revised form 27 Feb. 2010; accepted 6 Mar. 2010. J Forensic Sci, March 2011, Vol. 56, No. 2 doi: 10.1111/j.1556-4029.2010.01667.x Available online at: onlinelibrary.wiley.com Ó 2011 American Academy of Forensic Sciences 529