Mitral valve fibroelastoma

Ten Tumors in the Heart: Papillary Fibroelastoma with Triple Valve Involvement

Cardiac papillary fibroelastoma (CPF) is a benign tumor of endocardial origin, most frequently solitary, which commonly affects the aortic valve. We report the case of a 62-years-old woman with ten separate tumors that developed on the mitral, tricuspid, and pulmonary cusps, atrioventricular valve chordae, and left ventricular endocardium. Surgical treatment included valve-sparring resection of the pulmonary cusp tumors and bioprosthetic replacement of the mitral and tricuspid valves, which exhibited extensive tumor invasion. The postoperative course was unremarkable. The high number of CPFs and triple-valve tumor involvement are both exceptional. CPF should be considered whenever multiple cardiac masses are discovered.

Papillary Fibroblastoma of Tricuspid Valve with Pulmonary Embolization

A 53-year-old man was diagnosed with a papillary fibroelastoma of the tricuspid valve with pulmonary embolization and associated coronary artery disease. He underwent excision of the tumor and coronary bypass grafting. Due to potential embolization, it is recommended that all such fibroelastomas be excised.

Neurologic complications of cardiac tumors

Cardiac tumors are an uncommon cause for neurologic disease, but if undiagnosed can be associated with devastating neurologic consequences. Primary cardiac tumors, both benign and neoplastic, and metastatic tumors occur. Primary cardiac tumors are more likely to be associated with neurologic embolic complications. Metastatic cardiac tumors are more likely to be associated with valvular distraction, arrhythmia, diminished cardiac output and indirect neurological dysfunction. Primary and metastatic cardiac tumors may result in cerebral metastatic disease. Atrial myxoma, a benign primary cardiac tumor, is the most common cardiac tumor associated with neurologic disease, and most commonly causes cerebral embolization and stroke. The use of thrombolytic therapy for these strokes is controversial. Additionally, delayed manifestations, including aneurysm formation and intracranial hemorrhage, are possible. Aneurysm formation has been described as occurring after removal of the primary tumor. The availability of noninvasive cardiac imaging has significantly helped decrease the neurologic morbidity of cardiac tumors and has led to frequent successful intervention.

Cardiac papillary fibroelastoma: a retrospect of four cases

OBJECTIVE

We have reviewed the medical histories of 4 patients who underwent operations between November 2004 and February 2011 at Changhai Hospital for cardiac papillary fibroelastoma.

METHODS

Diagnosis was demonstrably suggested by echocardiography. Tumor locations were mitral valve (1), left atrium (1), and aortic valve (2). Indications for operation were previous cerebrovascular accident for the mitral tumor, incidental apopsychia and giant mobile mass for the left atrium, ingravescent chest tightness and palpitations for the first aortic tumor, and severe regurgitation of aortic valve for the second aortic tumor. The study was approved by the Changhai Hospital Ethics Committee, and the consent from the patients or their immediate family was obtained.

RESULTS

Surgical excision with necessary valve replacement operations was performed in all cases. All patients had uneventful postoperative recoveries. No evidence of regurgitation or recurrence was seen on echocardiography at follow-up.

CONCLUSIONS

Despite their histologically benign aspect, cardiac papillary fibroelastomas should be removed because of potential embolic complications.

Aortic valve papillary fibroelastoma associated with acute cerebral infarction: a case report

An 80-year-old woman with a history of congestive heart failure, atrial fibrillation, and hypertension was transferred to our institution with hematemesis. Her drug regimen included 2 mg warfarin potassium/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a mass attached to the noncoronary cusp and a cardiac tumor was suspected. The patient declined surgery and was meticulously followed up with periodic TTE. Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel; anticoagulant therapy was ceased. On day 15 of admission, acute cerebral infarction occurred. Heparin sodium and warfarin potassium were administered rapidly, and her symptoms improved. TTE revealed no alteration of the mobile, string-like mass attached to the noncoronary cusp. Cardiac tumor was considered the cause of cerebral infarction, and the patient consented to surgical therapy. Pathological examination of the resected tumor suggested papillary fibroelastoma (PFE). Although no guidelines exist for PFE management, a mobile, cardiac tumor necessitates surgical resection to prevent thromboembolic events, even when small in size.

Echocardiographic diagnosis of papillary fibroelastoma of the mitral and tricuspid valve apparatus

Papillary fibroelastomas are rare and normally benign cardiac tumors typically attached to cardiac valves. This report describes two patients who were evaluated for intermittent dyspnea in one case and for the source of cerebral embolism in the other. In both patients transthoracic echocardiography revealed a pedunculated mobile mass adjacent to an atrioventricular valve, suggestive of papillary fibroelastoma. Postoperative histology was confirmatory of papillary fibroelastoma with a typical hyalinized hypocellular stroma covered by a single layer of endocardial cells.

Nonsurgical management of a left ventricular pedunculated papillary fibroelastoma: a case report

Papillary fibroelastoma (PFE) is a benign cardiac tumor that has the potential to cause life-threatening embolic events. Surgical excision of the tumor is recommended for all patients who develop symptoms, but the treatment of asymptomatic patients with an echocardiographically identified PFE is still controversial. Our case report describes a 63-year-old patient with the incidental finding of a probable left ventricular PFE. The patient was not a candidate for surgical excision of this tumor because of comorbidities and refusal to undergo surgery. The patient was followed up during a period of 4 years and was kept on anticoagulation with warfarin. During this follow-up period, the patient developed no symptoms or complications attributable to the cardiac tumor. This is the first case reported in the literature with left ventricular mobile PFE conservatively managed for a duration of more than 4 years. Randomized controlled trials regarding the best management for such incidental PFEs may be needed.

Cardiac papillary fibroelastoma of the mitral chorda

We describe a case of cardiac papillary fibroelastoma in a 33-year-old man. The diagnosis was established by echocardiography. Computerised tomographic angiography gave no evidence of coronary stenosis, but illustrated a radiopaque filling defect in the left ventricle. The papillary fibroelastoma was removed together with the involved chorda, and an artificial chord was implanted under cardiopulmonary bypass. Histological study confirmed the diagnosis of papillary fibroelastoma. Due to the potentials of cerebral and coronary embolisation, surgical management to the patients with a papillary fibroelastoma is highly recommended.

Papillary fibroelastoma of the right atrium as an unusual source of recurrent pulmonary embolism

Papillary fibroelastoma is the most common primary tumour of cardiac valves, with the potential for embolic events and obstructive effects. Location in non-valvular endocardium is extremely rare. Transthoracic and transoesophageal echocardiography have greatly increased the ability to make the diagnosis of these surgically treatable tumours in a timely fashion. We report the case of a 70-year-old woman with symptoms and ventilation-perfusion scan evidence of pulmonary embolization from a papillary fibroelastoma of the right atrium. Initial transthoracic echocardiography failed to identify the tumour, whereas transoesophageal echocardiography demonstrated a mobile echodense mass attached to the right atrial free wall. After surgical excision, histopathology revealed papillary fibroelastoma. The epidemiology, aetiology, localization, macroscopy, histopathology, immunohistochemistry, clinical presentation, diagnosis and management of cardiac papillary fibroelastoma are reviewed. The case is unusual with respect to the site of origin of the papillary fibroelastoma as well as its clinical presentation, which is clearly related to pulmonary embolization.

Cardiac papillary fibroelastoma presents as an acute embolic stroke in a 35-year-old African American male

This is an interesting case of a young patient suffering an acute embolic stroke in the middle cerebral artery distribution, who was later found to have a papillary fibroelastoma on the mitral valve. The mass was first recognized by transesophageal echocardiography and eventually resected surgically. The retrieved specimen had classic histologic findings of a papillary fibroelastoma. A thrombus was noted on the tip of the specimen, supporting the theory that these masses are risks for strokes secondary to damage along the endothelial lining predisposing to subsequent fibrin deposition and mural thrombus formation.

Neoplasms involving the heart, their simulators, and adverse consequences of their therapy

Primary cardiac tumors involving the heart may be either benign or malignant. Most of the benign tumors are myxomas, which are most commonly located in the left atrium. Primary malignant neoplasms usually involve the myocardium and the interior of the cardiac cavities, whereas neoplasms metastatic to the heart most commonly involve pericardium, and pericardial effusion and constriction are the most common consequences. Computed tomography and magnetic resonance imaging are becoming the most useful instruments of precision for the diagnosis of cardiac tumors. Pericardial cysts, teratomas, lipomatous hypertrophy of the atrial septum, papillary fibroelastomas, thrombi, and sarcoid are frequently mistaken for cardiac neoplasms. There are a number of cardiac consequences of malignancy, including radiation heart disease, cardiac hemorrhages, cardiac infection, cardiac adiposity or the corticosteroid-treated heart, cardiac hemosiderosis, and toxicity due to anthracycline chemotherapy.

Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases

BACKGROUND

With the advent of echocardiography, cardiac papillary fibroelastoma (CPF) is being increasingly reported. The demographics, clinical characteristics, pathological features, treatment, and prognosis of CPF are examined.

DATA COLLECTIONS

Cases, case series and related articles on the subject in all languages were identified through a comprehensive literature search.

RESULTS AND CONCLUSIONS

Seven hundred twenty-five cases of CPF were identified. Males comprised 55% of patients. Highest prevalence was in the 8th decade of life. The valvular surface was the predominant locations of tumor. The most commonly involved valve was the aortic valve, followed by the mitral valve. The left ventricle was the predominant nonvalvular site involved. No clear risk factor for development of CPF has been reported. Size of the tumor varied from 2 mm to 70 mm. Clinically, CPFs have presented with transient ischemic attack, stroke, myocardial infarction, sudden death, heart failure, presyncope, syncope, pulmonary embolism, blindness, and peripheral embolism. Tumor mobility was the only independent predictor of CPF-related death or nonfatal embolization. Symptomatic patients should be treated surgically because the successful complete resection of CPF is curative and the long-term postoperative prognosis is excellent. The symptomatic patients who are not surgical candidates could be offered long-term oral anticoagulation, although no randomized controlled data are available on its efficacy. Asymptomatic patients could be treated surgically if the tumor is mobile, as the tumor mobility is the independent predictor of death or nonfatal embolization. Asymptomatic patients with nonmobile CPF could be followed-up closely with periodic clinical evaluation and echocardiography, and receive surgical intervention when symptoms develop or the tumor becomes mobile.

[Papillary fibroelastoma: a rare but treatable cause of cerebral infarction]

INTRODUCTION

Papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications.

EXEGESIS

We report on a 42-year-old man admitted for an ischemic stroke in the left middle cerebral artery region. Transesophageal echocardiography revealed a mitral valve tumor. Surgical excision and histological examination showed a papillary fibroelastoma. Clinical course was uneventful.

CONCLUSION

We consider the high embolic potential of this tumor, which represents a surgically treatable cause of ischemic stroke.

Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients

BACKGROUND

Cardiac papillary fibroelastoma (CPF) is a primary cardiac neoplasm that is increasingly detected by echocardiography. The clinical manifestations of this entity are not well described.

METHODS AND RESULTS

In a 16-year period, we identified patients with CPF from our pathology and echocardiography databases. A total of 162 patients had pathologically confirmed CPF. Echocardiography was performed in 141 patients with 158 CPFs, and 48 patients had CPFs that were not visible by echocardiography (<0.2 cm), leaving an echocardiographic subgroup of 93 patients with 110 CPFs. An additional 45 patients with a presumed diagnosis of CPF were identified. The mean age of the patients was 60+/-16 years of age, and 46.1% were male. Echocardiographically, the mean size of the CPFs was 9+/-4.6 mm; 82.7% occurred on valves (aortic more than mitral), 43.6% were mobile, and 91.4% were single. During a follow-up period of 11+/-22 months, 23 of 26 patients with a prospective diagnosis of CPF that was confirmed by pathological examination had symptoms that could be attributable to embolization. In the group of 45 patients with a presumed diagnosis of CPF, 3 patients had symptoms that were likely due to embolization (incidence, 6.6%) during a follow-up period of 552+/-706 days.

CONCLUSIONS

CPFs are generally small and single, occur most often on valvular surfaces, and may be mobile, resulting in embolization. Because of the potential for embolic events, symptomatic patients, patients undergoing cardiac surgery for other lesions, and those with highly mobile and large CPFs should be considered for surgical excision.

Calcified bicuspid aortic valve mass prolapsing into the left main coronary artery

We report a case of a mobile calcific mass on the aortic valve that prolapsed into the left main coronary artery of a 51-year-old man. This case and a review of the literature suggest that calcific embolization to coronary arteries is a rare but possibly underrecognized complication of calcified degenerative or bicuspid aortic valves. This potentially catastrophic complication of calcified aortic valves needs to be suspected and recognized in clinical practice.

Mitral papillary fibroelastoma as a cause of cardiogenic embolic stroke: report of two cases and review of the literature

Papillary fibroelastoma (PFE) is a rare benign tumour that attaches to the endocardial surface, mostly on cardiac valves. Though usually asymptomatic, it can be the source of several complications. To date, 49 cases have been reported of embolic stroke with a PFE as the probable origin.

CASE REPORTS

(i) a 39-year-old male presented with ischemic embolic stroke; the presence of a PFE was assessed by means of transoesophageal echocardiography and confirmed by pathological findings; (ii) a 32-year-old woman presented with sudden onset of left hemiparesis; a cardiogenic embolic stroke was suspected, and a diagnosis of PFE was made based on echocardiographic and pathological findings. In both cases, surgical excision of the tumours was performed with no recurrences at follow-up. Two mechanisms can explain the formation of emboli in PFE: dislodgement of the tumour leaves or fibrin-platelet aggregation on the endocardial surface of these leaves. Transthoracic echocardiography may lead to the suspicion of a PFE, but transoesophageal echocardiography is required for confirmation. Prompt surgical excision is indicated in most cases. Anticoagulation is only recommended in situations of high surgical risk and during the wait for surgery.

Papillary fibroelastomas

Papillary fibroelastomas are rare benign neoplasms, predominantly involving cardiac valves, that have been discovered with increasing frequency through the use of echocardiography. Most are papillary lesions, less than 1 cm in size, connected to the valve or mural endocardium by a small stalk. Although often asymptomatic, embolization from the lesion or attached thrombus may cause serious neurological or cardiac events. All symptomatic papillary fibroelastomas should be removed unless there are compelling contraindications, in which case anticoagulation is an acceptable but unreliable alternative. Surgical removal is safe, simple, effective, and permanent. Asymptomatic lesions of the left side of the heart should be removed because of their potentially serious or fatal consequences, whereas those arising from the right side of the heart may be observed.

Exophthalmos, pretibial myxedema, osteoarthropathy syndrome associated with papillary fibroelastoma in the left ventricle

EMO syndrome, a rare complication of Graves' disease, exhibits exophthalmos, pretibial myxedema, and osteoarthropathy. The presence of functional thyrotropin receptors (TSHR) in adipocytes and osteoblasts, both of which we have recently observed, may be related to these extrathyroidal manifestations of Graves' disease. In addition, the expression of TSHR in the heart has recently been reported. We describe here a patient with Graves' disease exhibiting EMO syndrome with a papillary fibroelastoma in the left ventricle. Pathological examinations showed that the fibroelastoma contained Alcian blue-stained mucinous materials that were also observed in the subcutaneous tissue of pretibial myxedema.

Mitral valve repair for anterior leaflet papillary fibroelastoma: two case descriptions and a literature review

Cardiac papillary fibroelastomas are rare cardiac tumors and have been considered a 'benign' incidental finding that may have significant clinical manifestations. In this paper we report two cases of mitral valve fibroelastoma: one was discovered by chance with transthoracic echocardiography in a young healthy man, the other was an intraoperative incidental finding in a middle aged man with a recent history of acute myocardial infarction. The mitral valve was repaired in both cases after excising the tumor. The patients did well and remain asymptomatic. A literature review was compiled which comprises previous case reports of 34 patients with mitral valve papillary fibroelastomas. Most were asymptomatic, but when symptoms occurred, they could be disabling, such as stroke, cardiac heart failure, myocardial infarction, and sudden death. Papillary fibroelastoma is amenable to simple surgical excision or in addition to mitral valve repair or replacement. Recurrence has not been reported.

Surgical treatment of a cardiac papillary fibroelastoma developing from the chordae of the tricuspid valve: report of a case

Papillary fibroelastoma is a rare, benign cardiac tumor that can cause multiple emboli. We report herein a case of papillary fibroelastoma developing from the chordae of the tricuspid valve which was detected by echocardiography and confirmed by surgical resection. To our knowledge, this is only the fifth documented case of a tricuspid valve papillary fibroelastoma detected by echocardiography in a living patient.

Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation

OBJECTIVES

We sought to determine the clinical and echocardiographic characteristics of papillary fibroelastoma (PFE).

BACKGROUND

PFE is a rarely encountered cardiac tumor about which relatively little is known.

METHODS

Institutional records were reviewed for the years 1980 to 1995 for patients with pathologic or echocardiographic diagnosis of PFE. Group 1 included 17 patients with the pathologic diagnosis of PFE who also underwent echocardiography. Echocardiographic features of PFE were established in group 1. Group 2 included 37 patients with only echocardiographic evidence of PFE.

RESULTS

In group 1, 7 (41.2%) of 17 patients had symptoms related to PFE. Neurologic events occurred in 5 (29.4%) of 17 patients. All patients had the tumor surgically removed. During follow-up, no new embolic events occurred. Echocardiographic characteristics of PFE included a small tumor (12.1 +/- 6.5 x 9.0 +/- 4.3 mm), usually pedunculated (14 [94%] of 17 patients) and mobile, with a homogeneous speckled pattern and a characteristic stippling along the edges. PFEs were most common on valvular surfaces (12 [60%] of 20 PFEs) but were not uncommon on other endocardial surfaces (8 [40%] of 20 PFEs). The tumor did not cause valvular dysfunction. In group 2, 16 (43%) of 37 patients were asymptomatic. Five patients (13.5%) had a previous neurologic event. During follow-up (mean 31 months, range 1 to 77), nine neurologic events occurred.

CONCLUSIONS

PFEs are associated with embolism, can be diagnosed with echocardiography, are often an incidental clinical finding and do not cause valvular dysfunction.

Echocardiographic evaluation of papillary fibroelastoma: a case report and review of the literature

Papillary fibroelastomas comprise approximately 7.9% of benign primary cardiac tumors. Although papillary fibroelastomas were at first discovered incidentally at autopsy or during heart surgery, these tumors are increasingly being identified by echocardiography. This article reviews those papillary fibroelastomas detected by transthoracic or transesophageal echocardiography and discusses the echocardiographic features of these tumors, associated symptoms, and management. Echocardiography is important in influencing management decisions regarding excision, valve replacement, and valve repair.

Branch retinal artery occlusion caused by a mitral valve papillary fibroelastoma

PURPOSE

We studied clinicopathologically a branch retinal artery occlusion caused by an embolus from a mitral valve papillary fibroelastoma.

METHODS

At initial examination the patient, a 37-year-old woman, had visual acuity of 20/400 in her left eye, and eight months later her visual acuity improved to 20/20. The diagnosis required echocardiographic and radiologic studies to localize the lesion.

RESULTS

The mitral valve papillary fibroelastoma was successfully treated with tumor resection involving the mitral valve.

CONCLUSIONS

It is important to diagnose intracardiac papillary fibroelastoma, because it can cause recurrent arterial embolization and because it responds favorably to tumor resection.

Cardiac papillary fibroelastoma

Papillary fibroelastomas are rare cardiac tumors, but they are the most common primary tumor of the heart valves. These lesions occur on any of the valves or endothelial surfaces of the heart and may be detected by echocardiography, cardiac catheterization, during open heart operation for other conditions, or at autopsy. Because of their potential for cerebral and coronary embolization, even small papillary fibroelastomas should be excised.

Transesophageal echocardiography in the detection and surgical management of a papillary fibroelastoma of the mitral valve causing partial mitral valve obstruction

Primary mitral valve tumors are rare. We describe the transesophageal appearances of a papillary fibroelastoma (Lambl's giant excrescence) of the anterior mitral valve leaflet causing partial mitral valve obstruction. Transesophageal echocardiography proved particularly useful in identifying the limited attachment of the tumor to the anterior mitral valve leaflet and excluding its attachment to the interatrial septum. These features helped to exclude the possibility of the tumor being a left atrial myxoma, the primary differential diagnosis of the lesion. Transesophageal echocardiography enabled the planned surgical option to be mitral valve repair and also allowed intraoperative monitoring to assess the results of the surgical repair.

Papillary fibroelastoma in the left ventricular outflow tract

We report a case of a papillary fibroelastoma originating from the left ventricular endocardium in the outflow tract which was discovered by echocardiography in an asymptomatic patient. Two echocardiographic features were observed: (1) the tumor surface was smooth, and characteristic papillary formation was not detected; and (2) the outline of the mass was clearly defined as a dense echo, with the central, radiolucent, portion surrounded by a highly refractive linear echo at the level of the maximum diameter of the mass. The excised tumor was covered with a gelatinous substance that masked multiple papillae on the surface, but its echolucent center could not be explained by the pathology of the tumor which was solid centrally. Our case indicates that a papillary fibroelastoma may sometimes show echocardiographic findings similar to those of a myxoma, although other investigators have not noted the smooth surface and the echolucent center makes it indistinguishable from a myxoma. Thus, in some cases, it is difficult to distinguish papillary fibroelastoma from myxoma by echocardiography.