the neoplastic process is asymptomatic until the tumor starts exerting pressure on the surrounding organs , impairing their function . the primary focus may develop in the uterus , while the most common locations of secondary tumors include the retroperitoneal space [ 2 , 3 ] . metastases in the area of the heart are not typical of leiomyosarcoma , but such cases have also been reported [ 411 ] . the patient was an obese woman , aged 61 , with a long history of hypertension , treated with continuous positive airway pressure ( cpap ) for obstructive sleep apnea . her medical history included incidents of angioedema during attempts at antihypertensive treatment with angiotensin - converting enzyme ( ace ) inhibitors . from 2004 , the patient underwent numerous surgical procedures ( extirpation of the uterus , removal of a tumor in the right lumbar area , removal of a tumor in the right thigh , removal of a tumor in the left arm ) . the patient was referred to the cardiology clinic after a cardiac tumor was revealed in follow - up echocardiography . the tumor with jagged edges ( 35  35 mm ) filled the apical portion of the left ventricle . cardiac diagnostics was conducted due to the gradually deteriorating exercise tolerance , even though the patient 's fatigability could have been attributed to her age , body type , inactive lifestyle , and long - term hypertension with left ventricular hypertrophy leading to diastolic heart failure . regular cardiac function in physical examination ( 76/min ) , quiet systolic murmur in the apex and erb 's point , no auscultatory changes over the lung fields , trace of peripheral swelling , and normal blood pressure with the currently applied treatment were noted . after a cardiological consultation , due to the fact that the echocardiographic image clearly corresponded to a metastatic course of leiomyosarcoma , other methods of diagnostic imaging were not utilized ( fig . the patient was operated on with cardiopulmonary bypass , under systemic hypothermia ( 28c ) , using crystalloid cardioplegia . the left ventricle was opened on the anterior wall between the posterior interventricular artery and the diagonal branch . a large tumor ( 3  3 cm ) was removed from the wall of the left ventricle with the coagulation of the cut edges . aortic cross - clamping time during the procedure was 19 minutes , while cardiopulmonary bypass time was 45 minutes . the early postoperative period at the intensive care unit was extended due to low cardiac output syndrome ( ef 26% ) , requiring the inclusion of catecholamines , and bradyarrhythmia , necessitating  temporary external cardiac pacing . the patient was moved to the cardiology clinic on the 15 postoperative day ( fig . 2 and 3 ) . 100/min , blood pressure  135/85 mmhg , crackles at the base of both lungs , traces of lower leg swelling , lack of postcardiotomy syndrome in echocardiography . signs of heart failure requiring the implementation of an appropriate treatment were dominant during subsequent hospitalization . due to the presence of angioedema in the patient 's medical history , ace - i ( angiotensin - converting - enzyme inhibitor ) treatment was not applied . a follow - up echo examination revealed a slight improvement in left ventricular ejection fraction ( lvef 30% ) . the tumor is marked with an arrow echocardiographic image taken on the 15 day after tumor resection , apical four - chamber view echocardiographic image taken on the 15 day after tumor resection , tissue doppler imaging . high e / e ratio indicates increased left ventricular filling pressure the applied pharmacological treatment stabilized the patient ( nyha iii ) ; a six - minute walk test with exercise tolerance at the level of 280 m was conducted before discharge . due to the radical nature of the tumor resection , no supplementary methods of treatment were implemented . the period of outpatient treatment , including cardiac rehabilitation , was uneventful ; the condition of the patient was stable , with a gradual improvement of physical performance ( nyha iii  nyha ii ) . after 3 months , a follow - up echocardiographic examination showed a further improvement of left ventricular ejection fraction ( lvef 38% ) . currently , the long - term follow - up exceeds 12 months ; no new neoplastic foci were found in echo and computed tomography ; left ventricular ejection fraction remains stable ( lvef 40% ) . the good clinical condition of the patient enables her to conduct her daily activities at a level sufficient for her needs . the most common benign cardiac tumors include myxoma ( approximately half of all cases ) , papillary fibroelastoma , and lipoma ( 16% for each type ) . sarcomas constitute the dominant group of malignant tumors ( 95% ) , the most common being angiosarcoma ( 28% ) . it is important to emphasize that metastatic heart tumors are over 20 times more frequent than primary tumors and are found in 10 - 12% of patients with neoplastic diseases . heart metastasis occurs most frequently in the course of lung , breast , and kidney cancers as well as in the case of lymphomas and melanoma . the prevalence of leiomyosarcoma in the adult population is estimated at 5% of all cardiac tumors and 1% of all neoplasms . leiomyosarcoma is most commonly localized in the retroperitoneal space ( 19% ) , but it may also develop in the uterus , stomach , intestines , skin , and vascular walls . leiomyosarcoma of the heart is usually located in the left atrium , but it may also occur in the left ventricle , as in the case presented above . it is assumed that some of them may develop from the smooth muscles of pulmonary veins . due to their oligosymptomatic course , cardiac tumors are underdiagnosed ; diagnosis is established intraoperatively or during an autopsy . the development of medical imaging methods enabled earlier diagnosis of cardiac tumors . due to the slow and asymptomatic growth and lack of specific biochemical markers , the main role in diagnostics is played by imaging methods , mainly ultrasound . in the case of cardiac tumors , an echocardiographic diagnosis of a cardiac tumor requires differentiation ; apart from tumors , it is necessary to consider thrombi or bacterial vegetation . the final diagnosis is frequently reached through correct differentiation based on the patient 's disease history as well as tumor location and structure . other methods of medical imaging used in the diagnostics of cardiac tumors include transesophageal echocardiography and computed tomography . the results of imaging examinations enable the assessment of the anatomical condition in the area of the tumor , which allows for the establishment of the extent of myocardial , pericardial , and extracardiac involvement . possible clinical symptoms : tumors in cardiac cavities usually cause heart failure with its typical symptomatology , while cardiac dysrhythmia may be expected in the case of intramural tumors . the clinical manifestation of cardiac tumors is dependent on the influence of tumor location and size on the hemodynamics of the heart . moreover , left heart tumors may cause embolisms in the systemic circulation , in the form of ischemic stroke , infarctions of abdominal organs , and peripheral embolisms in extremities . in advanced forms of the disease , tumor growth is frequently accompanied by the presence of bloody exudate in the pericardial sac , which may result in the development of life - threatening tamponade . the general operative indications for cardiac tumors result from the hemodynamic disorders associated with tumor growth , increased risk of embolism , and cardiac dysrhythmia . the main factors determining the results of cardiac surgical treatment include the general condition of the patient , the stage of the underlying neoplastic process ( infiltration by continuity ) , and the occurrence of clinically significant distant metastases ( crucial for prognosis ) . therefore , surgical treatment is rarely applied , and long - term surgical treatment results are poor . in the case of the present patient , the ailments were associated with heart failure in nyha class ii ; however , as a result of the irregular , jagged surface of the tumor revealed in echocardiography , this form of the disease was characterized by increased risk of embolic complications . the condition of the patient , anatomy of the tumor , and lack of metastases to other organs at the current stage of the disease enabled the qualification of the patient for surgical treatment . in the case of malignant tumors , a surgical procedure is not a fully effective method of treatment , but isolated cases of lasting recovery after radical tumor resection have been described in the literature . the factors determining unfavorable prognosis include incomplete tumor resection and high grade of tumor differentiation ( g3 ) leading to the rapid spread of metastases , mainly to the lungs and the brain . the effectiveness of adjuvant radio- and chemotherapy in the treatment of leiomyosarcoma has not yet been explicitly established , while the applied therapeutic schemes were transferred from the treatment of soft tissue sarcomas . in the present case , the occurrence of low cardiac output syndrome , treated with a catecholamine infusion , and symptomatic bradyarrhythmia , requiring temporary external cardiac pacing , constituted significant problems in the early postoperative period . the complications were associated with the extent of the procedure , the necessary coagulation of the tumor resection line with subsequent necrosis of the adjacent tissue , and postoperative myocardial stunning . the applied pharmacological treatment and cardiac rehabilitation enabled the reduction of heart failure symptoms to nyha class ii , with a gradual improvement of left ventricular ejection fraction . a standard management after cardiac tumor resection is yet to be established ; the prognosis is not certain due to the risk of local recurrence , occurring in half of the patients undergoing surgery , as well as the appearance of metastases , observed in 20 - 40% of cases . in cases of primary cardiac tumors and incomplete tumor resection , the average time of survival is estimated at 6 to 12 months , while , in the case of radical tumor resection , various reports estimate it at 24 - 45 months ; radical procedures may consist in autotransplantation with the reconstruction of the removed elements of the heart . the majority of reports concerning cardiac surgery and adjuvant chemotherapy , however , estimate the average survival time at approximately 18 months . sarcomas are characterized by the recurrence of hyperplasia , which necessitates regular clinical monitoring with diagnostic imaging methods ( watchful waiting strategy ) . in the case of leiomyosarcoma , it is recommended to carefully consider the possibility of local recurrence and metastasis to the brain and lungs . currently , the long - term follow - up of the present patient exceeds 12 months . the good clinical condition of the patient enables daily activity at a level sufficient for her needs .
we present a case report of a 60-year - old woman with a long history of leiomyosarcoma in different locations . 
 she was admitted to the clinic due to a left ventricular tumor diagnosed in echo examination . 
 the patient was qualified for radical tumor resection . 
 the early postoperative period was complicated due to low cardiac output syndrome and bradyarrhythmia requiring temporary cardiac pacing . 
 optimized pharmacological therapy resulted in a gradual reduction of symptoms and a clinical improvement of congestive heart failure ( nyha iii  nyha ii ) . due to the radical nature of the surgery , 
 the patient was not referred for supplementary treatment . 
 the follow - up currently exceeds 12 months  no new metastases have been found . 
 this case provides an example of how to diagnose and treat heart tumors .