Hepatic hemangioma presenting as cardiac failure and pulmonary hypertension in a preterm infant: A case report and literature review

Introduction: Hepatic hemangiomas are the most common benign vascular liver tumours in neonates and are usually characterized by rapid growth followed by involution. They are classified as congenital or infantile and may present incidentally or with complications such as consumptive coagulopathy, rupture, or cardiac failure. This case report describes a preterm infant with a giant hepatic hemangioma manifesting as severe cardiac failure and pulmonary hypertension, and requiring multidisciplinary management. Case Presentation: This article describes the case of an ex-27-week male infant with persistent non-invasive respiratory support dependence for chronic lung disease presented at 40+4 weeks post-menstrual age with respiratory deterioration, generalized edema, and cardiomegaly. Echocardiography showed right ventricular dilation, tricuspid regurgitation, and pulmonary hypertension. Abdominal imaging revealed a large hepatic mass consistent with a giant cavernous hepatic hemangioma. The infant's high-output congestive cardiac failure was believed to be caused by the large volume of left-to-right shunting at the level of the hepatic hemangioma. Initial management with diuretics and sirolimus failed to improve symptoms significantly, necessitating catheter-based embolization of the mass-feeding vessels. The procedure resulted in rapid clinical improvement, allowing weaning off respiratory support and diuretics. The patient was discharged at a corrected age of 48+4 weeks with continued sirolimus therapy. At 17 months of age, he remained stable without recurrence of symptoms. Conclusion: This case highlights the importance of differentiating congenital hepatic hemangiomas (CHs) from infantile hemangiomas to guide treatment, as CHs are often unresponsive to beta blockers. Unlike previous reports, this case involved a preterm infant whose hemangioma grew ex-utero, requiring both sirolimus and embolization for resolution. Future cases may benefit from earlier identification and a tailored, multidisciplinary approach to optimize outcomes.