The management dilemma of a large left ventricular fibroma.

Background: Cardiac fibromas are rare, benign primary cardiac tumours predominantly observed in paediatric populations, with their occurrence in adults being exceptionally uncommon. Case summary: We present the case of a 40-year-old physically active male with an incidentally discovered, large left ventricular fibroma during investigation for presumed ischaemic heart disease. Multimodal imaging, including computed tomography (CT) coronary angiography, transthoracic echocardiography, cardiac magnetic resonance imaging, and positron emission tomography-CT, revealed a 42 × 30 × 58 mm myocardial mass with significant calcification and myocardial invasion, ultimately diagnosed as a fibroma via biopsy. Given the patient's asymptomatic status, frequent ventricular ectopics, and high surgical risk associated with resection, a conservative management strategy was adopted. This included regular Holter monitoring and echocardiography to assess for arrhythmias, tumour progression, or functional compromise. The case underscores the limited evidence available for managing cardiac fibromas in adults, necessitating extrapolation from paediatric data and an individualized, patient-centred approach. Discussion: This report highlights the challenges of decision-making in adult cardiac fibromas, particularly regarding arrhythmogenic potential and surgical considerations, and emphasizes the need for further studies to establish evidence-based guidelines for this rare condition.