Primary cardiac valve tumors

Cardiac Papillary Fibroelastoma and Cerebrovascular Events: A Systematic Review

Background

Cardiac papillary fibroelastomas (CPFs) are benign endocardial tumours with embolic potential. This article is a systematic review to identify the clinical profile, diagnosis, tumour characteristics, and treatment modalities in patients with CPF presenting with stroke or transient ischemic attack (TIA).

Methods

This systematic review was conducted using the PubMed and Embase databases, including case reports and/or series and observational studies (for a search period of up until April 2022). A descriptive summary of case reports and/or series, and a narrative summary of observational studies, were completed.

Results

A total of 161 cases were identified from 133 case reports and 11 case series. The mean age of patients was 54.8 years, and 46.6% were male. TIA and stroke were reported in 32.3% and 67.8%, respectively. The most common stroke territory was multiple brain sites (36.6%). The mean tumour size was 11.8 mm. Most of the tumours were left-sided (98.7%). The mitral valve was the most involved valve (38.9%), with the anterior leaflet being the commonest site (61.3%). A total of 91.4% of tumours were independently mobile; 10.6% of tumours missed by transthoracic echocardiography were identified on transesophageal echocardiography. Antiplatelet and anticoagulation treatment were used in 87.9% and 12.1% of cases, respectively. Simple excision, valve repair, and valve replacement were performed in 66.7%, 16.7%, and 16.7%, respectively. The logistic regression model revealed that age was the only significant predictor; an increase in the log-odds of recurrent cerebrovascular events occurred with increasing age.

Conclusions

CPFs are a differential diagnosis of cryptogenic stroke, especially if the initial workup for stroke is negative. Transesophageal echocardiography serves as a better imaging tool, compared to transthoracic echocardiography, in identifying CPF. Although the consensus for CPF management remains controversial, surgical excision is the primary approach for left-sided CPF presenting as stroke or TIA.

Aortic valve fibroelastoma presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA): A case report and review of the literature

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac tumors more often involving the left-sided valves and related with threatening embolic complications. We report the case of a 35-year-old woman presenting with relapsing-remitting chest pain and elevated cardiac troponins. After a negative coronary angiography, an integrated imaging assessment based on echocardiography and cardiac magnetic resonance showed a pedunculated mass on the aortic valve causing an intermittent obstructive engagement of the right coronary ostium. A tailored surgical treatment was performed and the histopathological examination of the specimen revealed mesenchymal tissue with the characteristics of CPF.

Congenital Blood Cyst of a Child: A case report and review of literature

Blood-filled cysts of the heart valves are frequently reported at postpartum autopsies of infants. They are seen as round nodules mostly in the paediatric age group in infants less than 2 months of age and disappear spontaneously within 6 months of life. We report a unique case of an 11-month-old girl who presented at a tertiary healthcare hospital in 2022 with a blood-filled cyst on the posterior leaflet of the pulmonary valve that was successfully treated. This case report highlights the characteristics and course of a paediatric patient with blood-filled cysts. Further studies are yet needed to better understand the diagnostic approaches to blood-filled cysts as well as treatment modalities to fill the gap in clinical settings.

A rare case of papillary fibroelastoma involving the tricuspid valve. A single center experience over a period of 22 years (1999-2021)

BACKGROUND AND AIM

Papillary fibroelastoma (PFE) represents only 16% of the benign cardiac tumor and approximately 15% of these are located on the tricuspid valve.

MATERIALS AND METHODS

Over a period of 22 years (1999-2021) we observed 75 pts with cardiac tumors at our Center over 9650 pts operated on but only one case of a tricuspid valve PFE in a 69-year-old patient. Trans-thoracic echocardiography demonstrated a mobile mass (20 × 10 mm), adhering to the atrial side of the septal leaflet of the tricuspid valve of unknown origin. In consideration of the mobility of the mass and the consequent high embolic risk, surgical removal was made. The patient underwent surgery through a median sternotomy on CPBP. A 'gelatinous' mass adhering to the tricuspid leaflet was found and completely removed. The postoperative course was uneventful. The pathological diagnosis was PFE.

CONCLUSIONS

PFEs of the tricuspid valve are rare entities being in most cases found incidentally. In our experience, the incidence of this tumor in this location is 1/10,000 cases of cardiac surgery. Although most patients are asymptomatic, surgical treatment is nevertheless recommended in consideration of the high embolic risk.

Echocardiographic Evaluation of Cardiac Masses

PURPOSE OF REVIEW

Cardiac masses encompass a broad range of etiologies and are often initially revealed by echocardiography. The differential may change depending on the location of the mass and patients' medical history or presentation. It is important for clinicians to be aware of subtle visual characteristics on echocardiography in order to correctly diagnose the pathology.

METHODS

Patients who underwent transthoracic echocardiography and were found to have one or more cardiac masses between January 1, 2020, and May 15, 2023, were reviewed. Their demographic data, clinical presentation, medical history, imaging, and follow-up information were collected from hospital electronic medical records, de-identified, and used to complete this review paper. A detailed review of cardiac masses divided by cardiac chamber accompanied by real-world echocardiographic images from patients in a large inner city public hospital. We hope that this systematic review of cardiac masses with real-world echocardiographic images will help clinicians note subtle echocardiographic characteristics to aid in the diagnosis and treatment of cardiac masses.

Capillary haemangioma of the tricuspid valve annulus: A rare presentation

INTRODUCTION AND IMPORTANCE

To the best of our knowledge, very few tricuspid valves (TV) haemangiomas have been reported to date in the literature due to the avascular nature of the cardiac valve. We report the case of an otherwise healthy male presented with unexplained shortness of breath who was found to have tricuspid valvular haemangioma.

CASE PRESENTATION

52-year-old male who presented with progressive dyspnoea on exertion for 6 months. Echocardiography revealed an echo-dense mass attached to the heart's anterior leaflet of the tricuspid valve. A cardiac MRI suggested it as pulmonary fibroelastoma, but a surgical excision biopsy revealed it to be a capillary haemangioma. Patient symptoms improved after surgery.

CLINICAL DISCUSSION

Cardiac valve tumour-like haemangiomas are rare, with the involvement of the tricuspid valve even rarer. Most TV haemangiomas are detected incidentally, however, they may present with a range of symptoms. Echocardiography is the mainstay of diagnosis however definitive diagnosis is by histopathology. Surgical excision is the treatment of choice, though surgery in asymptomatic patients is still controversial.

CONCLUSION

Cardiac haemangiomas are rare, with the involvement of the tricuspid valve even rarer. They should undergo surgical excision due to the risks of embolism, rupture, and sudden death.

Gender-Related Outcomes after Surgical Resection and Level of Satisfaction in Patients with Left Atrial Tumors

BACKGROUND

Cardiac tumors are rare, with a low incidence of between 0.0017 and 0.19%. The majority of cardiac tumors are benign and predominantly occur in females. The aim of our study was to examine how outcomes differ between men and women.

METHODS

From 2015 to 2022, 80 patients diagnosed with suspected myxoma were operated on. In all patients, preoperative, perioperative, and postoperative data were recorded. Such patients were identified and included in a retrospective analysis focused on gender-related differences.

RESULTS

Patients were predominantly female (n = 64; 80%). The mean age was 62.76 ± 13.42 years in female patients and 59.65 ± 15.84 years in male patients (p = 0.438). The body mass index (BMI) was comparable in both groups: between 27.36 ± 6.16 in male and 27.09 ± 5.75 (p = 0.945) in female patients. Logistic EuroSCORE (LogES) (female: 5.89 ± 4.6; male: 3.95 ± 3.06; p = 0.017) and EuroSCORE II (ES II) (female: 2.07 ± 2.1; male: 0.94 ± 0.45; p = 0.043), both scores to predict the mortality in cardiac surgery, were significantly higher in female patients. Two patients died early, within 30 days after surgery: one male and one female patient. Late mortality was defined as the 5-year survival rate, which was 94.8%, and 15-year survival rate, which was 85.3% in our cohort. Causes of death were not related to the primary tumor operation. The follow up showed that satisfaction with surgery and long-term outcome was high.

CONCLUSION

Predominately female patients presented with left atrial tumors over a 17-year period. Relevant gender differences aside from that were not evident. Surgery could be performed with excellent early (within 30 days after surgery) and late results (follow up after discharge).

Recurrent acute coronary syndrome caused by a primary aortic valve sarcoma: grand rounds and literature review

Background

Malignant tumours of the aortic valve apparatus are extremely rare and difficult to diagnose. Their proximity to the coronary ostium may cause an acute coronary syndrome (ACS) either by infiltration or by embolization.

Case summary

We report a case of primary aortic valve undifferentiated sarcoma causing recurrent episodes of ACS, and we provide a literature review for primary cardiac valve tumours. This case also highlights the need for further evaluation of other causes of ACS in patients with minimal coronary artery disease risk factors and recurrent ACS.

Conclusions

The majority of valve tumours are fibroelastomas. Sarcomas are rare and lead to poor outcomes.

Unusual large mass on aortic valve in an infant

Mass on the aortic valve is extremely rare in children, and the differential diagnosis includes vegetation, thrombus, and primary cardiac tumors. A rise in infective endocarditis in infants is seen due to increasing survival of children with congenital heart diseases and sick newborn infants with prolonged hospitalization. We report a 4-month-old infant born prematurely with early-onset sepsis requiring prolonged antibiotic treatment and valvular aortic stenosis presenting with sudden hemodynamic compromise due to aortic vegetation extending into the ascending aorta eroding through its posterior wall. The report details management of our case and a brief description of available alternative treatment strategies.

Pulmonary valve myxoma requiring pulmonary valve replacement: a case report

Background

Most cardiac myxomas occur in the atria. Myxomas arising from the heart valves are rare, and there are only a few reports of myxomas arising from the pulmonary valve. Complete resection and prevention of embolization at the time of the first surgery are important to prevent the recurrence of myxomas.

Case presentation

An 82-year-old female was scheduled to undergo surgery for a fracture of the right femoral neck. The preoperative echocardiography showed a mass in the right ventricular outflow tract. The mass was 36 × 30 mm in size and entered into the pulmonary artery during systole. Cardiac synchronous computed tomography showed a stalked bifurcated mass near the pulmonary valve, which was suspected to be a myxoma. Surgical findings showed a lumen-occupying tumor when the main pulmonary artery was incised. Since the tumor was a single mass with a stalk on the pulmonary valve (right and left pulmonary valve cusps), tumor resection and pulmonary valve replacement (bioprosthetic valve) were performed. A right prosthetic femoral head insertion was performed on postoperative day 36, and the patient was transferred to the hospital on postoperative day 44. However, 1 year later, the patient developed a large myxoma (recurrence) that completely occluded the right pulmonary artery and died of right heart failure.

Conclusions

We report the case of a patient with a very rare myxoma arising from the pulmonary valve, which was treated with tumor resection and pulmonary valve replacement surgery; however, the patient developed another myxoma 12 months later and this tumor was larger than the primary tumor. The surgical margins were indistinct, and there was a high possibility of residual tumor in the pulmonary artery wall; hence, an extended resection should have been considered. The recurrence of myxoma, in this case, suggests that it is important to completely resect the primary tumor during the first surgery and to prevent intraoperative embolization.

Case Report: A Tale of a Cardiac Mass: Looks Like a Papillary Fibroelastoma, Acts Like a Non-bacterial Thromboendocarditis

Introduction: Benign cardiac tumors and tumor like conditions are a heterogeneous collection of mass lesions that vary widely in their characteristics, such as presentation, size, and location. In some instances, these tumors are found incidentally, and therefore a broad differential diagnosis should be considered.

Case: An elderly male with significant unintentional weight loss and a high risk for cancer presented with an incidental valvular cardiac mass. The mass was thought to be a non-bacterial thromboendocarditis on initial clinical evaluation. After multiple imaging modalities, the mass was suspected to be a papillary fibroelastoma (PFE), which was resected due to high stroke risk and multiple previous chronic infarcts on brain MRI.

Conclusion: This case highlights the need for a comprehensive cardiac evaluation of a valvular tumor to discern the etiology and rule out other underlying pathophysiological processes that may require alternative interventions to cardiac surgery.

Primary mitral valve angiosarcoma: A multifaced ultra-rare tumor

Malignant primary cardiac valve tumors are extremely rare neoplasms usually remaining silent up to late advanced stages. Getting to know the various features of this latent tumor, which needs prompt intervention, can assist in the earlier diagnosis. Herein we report a 24-year-old woman with angiosarcoma that originated from the mitral valve and manifested itself through dyspnea and pulmonary edema. The case is noteworthy with respect to appealing echocardiographic images.

A very rare case of incidental aortic valve fibrolipoma

Cardiac valve fibrolipomas are extremely rare. We report a case of a 38-year-old female initially presenting with palpitations and moderate aortic incompetence who was found to have a lipomatous growth of the aortic valve. She underwent aortic valve repair with good postoperative results. Histopathogy verified the lesion as a fibrolipoma. This is the first reported case of fibrolipoma in the aortic valve, whilst aiming to consider repair as a surgical option in young patients with such growths.

Nonsurgical Management of a Papillary Fibroelastoma of the Aortic Valve

We report the case of a 63-year-old woman who had an incidental echocardiographic diagnosis of papillary fibroelastoma (PFE) of the right coronary cusp of the aortic valve. The patient was informed about the embolic risk due to the pedunculated mass located on the aortic valve but she refused the proposed surgical removal. She was followed up yearly, and each follow-up included an echocardiographic evaluation of the mass. The lady is taking lysine acetylsalycilate 160 mg daily, and after more than 19 years later, she does not complain any symptoms or complications as a result of possible embolic episodes. If on one hand, our report is provocative for PFE nonsurgical management; on the other, we do believe that in symptomatic patients PFE located in the left heart chambers, the standard of care remains surgical excision after diagnosis. Anyway, our analysis shows that further data in this issue are needed in asymptomatic patients, and surgical indication should be proposed considering carefully the risk-benefit balance.

Surgery for Valvular and Nonvalvular Papillary Fibroelastomas

Papillary fibroelastomas (PFE) are benign neoplasms, mostly located on valvular surfaces with high embolic potential. This study presents a 27-year single institutional experience on surgical treatment of PFE in an adult patient- cohort with long-term follow-up. This study was approved by the institutional review board. Date and number of IRB approval: 11/23/2017, Institutional Review Board approval number A2014-0149. The need for individual patient consent was waived. We retrospectively evaluated all patients who underwent cardiac surgery for suspected space-occupying lesions in the observation period between June 1991 and June 2018 at our hospital. Clinicopathological features, imaging characteristics, surgical procedures and disease outcome were analyzed. 120 patients were diagnosed with various primary/secondary cardiac tumors and histology confirmed 21 PFEs were found in 16 patients. There was no significant age difference between patients with valvular vs nonvalvular PFEs (P = 0.26). Valvular lesions were found in aortic valve (n = 6), mitral valve (n = 2) and tricuspid valve (n = 1). Nonvalvular PFEs were found in right atrium (n = 2), left ventricle (n = 2), left atrial appendage (n = 2) and aortic wall (n = 1). Valvular lesions were significantly smaller in size compared to non-valvular lesions (P = 0.0013). Left-side PFEs were associated with a high embolization episodes (10/13 patients, 77%) not related to the size. One patient died in-hospital. All other patients were discharged out of the hospital postoperative. Follow-up was performed regularly for a median of 2.8 years (range 0.1-11 years) postoperative. Nonvalvular PFE tended to be larger in size and at least when located on the left sided heart had equally high propensity to embolize compared to valvular PFE. We strongly advocate surgical excision in all left-sided PFE.

Transapical Left Ventricular Approach for Cardiac Papillary Fibroelastomas: A Case Report

BACKGROUND/AIM

Cardiac papillary fibroelastomas (CPF) are benign tumors, frequently asymptomatic, characterized by a mobile pedunculated mass that arises from the endocardium. When CPF is located in the left ventricle, it may protrude into the left ventricular outflow tract and affect hemodynamics. They are highly thrombogenic, and can also cause some life-threatening events such as cerebral and peripheral embolization.

CASE REPORT

We herein report a case of a 74-year-old female admitted to our center with palpitations and dyspnea on exertion. Her past medical history revealed that she had had a transient ischemic attack 7 months before presentation. Echocardiography and cardiac magnetic resonance imaging revealed an intracardiac mass anchored in the anteroapical interventricular septum without interference with aortic or mitral valve functionality. Surgical resection of the left ventricular mass was performed through the left apical ventriculotomy approach. Histopathological examination of the tumor was suggestive of papillary fibroelastoma. The postoperative course was uneventful. The patient was discharged home on the eighth postoperative day, with no recurrence at 6 months.

CONCLUSION

Although left ventricular papillary fibroelastomas are benign tumors, they carry a high risk for embolic complications and therefore surgery should be proposed, the transapical approach being a safe and effective method.

The most influential papers in mitral valve surgery; a bibliometric analysis

This study is an analysis of the 100 most cited articles in mitral valve surgery. A bibliometric analysis is a tool to evaluate research performance in a given field. It uses the number of times a publication is cited by others as a proxy marker of its impact. The most cited paper Carpentier et al. discusses mitral valve repair in terms of restoring the geometry of the entire valve rather than simply narrowing the annulus (Carpentier, J Thorac Cardiovasc Surg 86:23–37, 1983). The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women’s Hospital in 1923 (Cohn et al., Ann Cardiothorac Surg 4:315, 2015). More recently percutaneous and minimally invasive techniques that were originally designed as an option for high risk patients are being trialled in other patient groups (Hajar, Heart Views 19:160–3, 2018). Comparison of percutaneous method with open repair represents an expanding area of research (Hajar, Heart Views 19:160–3, 2018). This study will analyse the top 100 cited papers relevant to mitral valve surgery, identifying the most influential papers that guide current management, the institutions that produce them and the authors involved.

[Papillary fibroelastoma in the cardiologist's practice]

The article presents a clinical case of diagnosis and treatment of a rare disease, multiple papillary fibroelastoma associated with a relapse and a complication in the form of cardioembolic stroke. The authors stressed difficulties in diagnostics of this disease and a special role of the physician-patient interaction.

Cardiac papillary fibroelastomas: A 10-year single-center surgical experience and long-term echocardiographic follow-up study

AIMS

Limited contemporary data are available on the clinical and echocardiographic outcomes after surgery for cardiac papillary fibroelastoma (CPF). The aim of this study was to review the clinical manifestations, pathological characteristics, surgical management, and prognoses of patients with histologically verified CPF, who underwent surgery at our cardiac surgery center from 2008 to 2018.

METHODS AND RESULTS

Twelve patients of median age 62 years (28 to 77 years) were treated. Embolic stroke or transient ischemic attack (five patients, 42%) were the only CPF clinical manifestations. Eleven (92%) tumors were localized on the valves, with the aortic valve being the most common tumor site (seven patients; 58%). Multiple factor analysis revealed no independent predictor of CPF-related embolization. Simple shave tumor excision was sufficient in most patients (10 patients, 83%). No operative or tumor-related late mortality during the median follow-up period of 4.7 years (1.1 to 10.2 years) was recorded. Asymptomatic metachronous valve tumor recurrence (in a location different from that of the original tumor) was revealed in two patients (17%) by transesophageal echocardiography (TEE), not detected by transthoracic echocardiography (TTE). One of these two patients underwent repeated surgery for CPF but later suffered a recurrent embolic stroke, due to another tumor recurrence.

CONCLUSION

CPF can be safely and effectively treated surgically. TEE is superior to the TTE option in CPF post-operative recurrence detection. There is a clear need for a prospective study to determine criteria for embolization risk stratification and optimum management in patients with CPF.

Giant Tricuspid Valve Fibroelastoma Incidentally Diagnosed During Routine Stress Testing

Papillary fibroelastomas (PFEs) are the most common valvular tumor, typically occurring on left-sided valves. We describe the evaluation and treatment of a giant tricuspid PFE in a healthy 43-year-old police officer who was referred for evaluation of frequent premature ventricular contractions during job-related treadmill stress testing. (Level of Difficulty: Beginner.).

Fibroelastoma in an unusual location: a rare cause of multiple cerebrovascular events

Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source.

Cardiac papillary fibroelastoma of a bicuspid aortic valve in an adolescent: A case report

Cardiac papillary fibroelastomas (CPFE) are exceptional primary benign cardiac tumours affecting the heart valves. We report here the case of a 15-year-old boy in whom echocardiography performed for non-specific chest pain during follow-up for bicuspid aortic valve showed as accidental finding the presence of a round mobile mass without stalk attached on the inferior side of the aortic valve. The mass did not cause any outflow tract obstruction or aortic insufficiency. Electrocardiogram-gated cardiac computed tomography and magnetic resonance imaging allowed to suspect CPFE. Although the patient was asymptomatic, open cardiac surgery with elective surgical resection of the tumour was performed to avoid systematic emboli. Histology confirmed the diagnosis of CPFE. This is an exceptional case of acquired CPFE in a young patient with bicuspid aortic valve. Due to the risk of systemic embolization, aortic or coronary ostium obstruction, elective excision of such lesions is recommended.

Multiple papillary fibroelastomas attached to left ventricular side and aortic side of the aortic valve: A report of new case and literature review

The aortic valve (AV) is the most commonly affected site in multiple papillary fibroelastomas, but the frequency of embolism caused by the attachment side of the AV has not been elucidated. According to the review of the previous literature, 16 cases have been found attached to the AV. Of these, 6 of these have been found to be attached on the aortic side and 4 on the left ventricular side, 1 was bilateral, and 5 cases were unknown. Of the cases found on the aortic side, embolism occurred in 3 of them, and of the left ventricular side cases, embolism occurred in 2 of them. The frequency of embolism is equivalent even if papillary fibroelastoma attached to either side of the AV.

Hemangioma of the Atherosclerotic Changed Aortic Valve

The incidence of heart valve hemangioma is very low and is mostly observed in the mitral and tricuspid valve. In 2006, two cases of aortic valve hemangioma were reported for the first time, including one with calcifying aortic valve stenosis. We now present a case of aortic valve hemangioma in a patient suffering from aortic valve insufficiency combined with atherosclerotic thickening.

Cardiac Excrescences of Unusual Origin

Mesothelial/monocytic incidental cardiac excrescences (cardiac MICE) are a rare finding that are most often discovered incidentally either upon echocardiography or invasive cardiovascular procedures. In total, less than 50 known cases have been reported since first being discovered over 30 years ago. They are typically benign lesions; however, there has been a reported case of cardiac MICE being responsible for severe cardiopulmonary compromise and another case of the lesion embolizing leading to cerebral infarctions and ultimately death. Cardiac papillary fibroelastomas are also uncommon lesions found in the heart though they are not as rare as cardiac MICE. They are also benign and are typically attached to valvular surfaces; however, they also can be found as mobile masses. Just as cardiac MICE, they are capable of causing turbulent flow and thrombus formation and have been reported as the cause of ischemic events due to their ability to embolize. We present a case of cardiac MICE and cardiac papillary fibroelastoma in an individual who initially presented with neurologic symptoms concerning for a cerebrovascular accident. The patient was found to have a left ventricular mass composed of both cardiac MICE and cardiac papillary fibroelastomas.

Tricuspid Papillary Fibroelastoma at Multimodal Imaging

Papillary fibroelastoma is a rare benign cardiac tumor, second after cardiac myxoma as more frequent cardiac valvular tumor. The therapy is usually based on surgery according to size, mobility, symptoms, and risks of surgery. We report the case of a 67-year old female with transient ischemic attack. Echocardiography showed the presence of a round mobile formation localized on the atrial side of septal leaflets of tricuspid valve, first identified as an endocarditis vegetation. Cardiac magnetic resonance (cMRI) confirmed the presence of the mass and showed an isointense signal in T1-turbo spin echo sequences, hypointense in cine steady-state free precession and in first-pass sequences, and hyperintense in T2 and phase-sensitive inversion recovery with central hypointense core, with a suspected diagnosis of fibroelastoma. The patient underwent cardiac surgery and histology confirmed the presence of fibroelastic tissue with papillary extroflexions compatible with diagnosis of fibroelastoma. The use of cMRI may be useful in the evaluation of the exact position, dimensions, and nature of cardiac masses and fibroelastomas, diagnostic workup, and preliminary assessment before surgery.

Retrospective analysis of 11 cases of primary cardiac valve tumors

OBJECTIVE

To explore the clinical features and surgical treatment experience of primary cardiac valve tumor.

METHODS

The present study retrospectively analyzed the clinical data of 11 patients with primary valvular tumors who underwent surgical treatment in our department from 1980 to 2016. Echocardiography of preoperative patients was indicated as a heart valve tumor. All patients underwent cardiopulmonary bypass surgery after endocardial angiography and positron emission tomography-computed tomography diagnosis, including four tumor resections-valvuloplasty and seven tumor resections-heart valve replacement. Pathological analysis was performed on all tumors. Postoperative cardiac ultrasound was followed up. Pathological analysis was performed on all tumors. All patients underwent postoperative ultrasound follow-up examination.

RESULTS

Primary valvular tumors are rare, accounting for only 0.034% (11/32.728) of extracorporeal circulation surgery in our center. It accounts for 2.8% (11/399) of primary cardiac tumors in the same period. Pathological study indicated that there were 10 cases of benign tumor and 1 case of low-grade sarcoma. After 0.6-16 years of follow-up, the operation effect was satisfactory.

CONCLUSION

Most of these tumors are papillary fibroelastoma located on the mitral valve, and surgical operation is the best strategy for cardiac primary valve tumors.

Mitral valve papillary fibroelastoma as a cause of acute coronary syndrome

A 37-year-old man presented with acute chest pain, an unremarkable ECG and mildly elevated cardiac troponin. Coronary CT angiography showed a calcium score of 0 together with the absence of atherosclerotic plaques and normal origin and course of the coronary arteries. Transthoracic and transoesophageal echocardiography revealed an infracentimetric round-shaped mobile mass attached to a secondary tendinous chord of the anterior mitral valve leaflet. Cardiac magnetic resonance further evidenced localised contrast uptake supporting vascular irrigation, making thrombus unlikely. After surgical excision, the patient had an uneventful postoperative course. Histopathology disclosed the typical collagenous matrix covered by a single cell layer. Although mostly benign, cardiac tumours are prone to embolisation and can thus mimic an acute coronary syndrome. Multimodality imaging has an important role in unmasking the true mechanism, revealing less common aetiologies and elucidating the possibility of curative surgical resection.

A Large Cardiac Papillary Fibroelastoma Arising from the Coumadin Ridge: Unusual Location and Presentation

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The coumadin ridge is a very unusual location for a cardiac PFE.

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Although benign, large, mobile cardiac PFEs can pose a significant embolic risk.

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Multimodality CV imaging can differentiate cardiac PFE from other cardiac tumors.

MR Imaging of Cardiac Masses

Cardiac masses present a diagnostic challenge given their relative rarity and the overall difficulty imaging the heart. With the increasing frequency and quality of imaging in general, however, the incidental discovery of cardiac masses is increasing. Cardiac masses seldom produce symptoms, and they are more commonly found during imaging for noncardiac indications. While echocardiography is useful in the initial evaluation of a suspected mass, cardiac magnetic resonance (MR) imaging is the best imaging modality to characterize cardiac tumors due to its superior tissue characterization and its higher contrast resolution. Due to the risk of embolization and arrhythmia, most benign cardiac tumors are removed, and imaging plays an important role in treatment planning. While primary resection remains the mainstay of treatment, new treatment strategies may prolong survival and slow the growth of metastases. A fundamental knowledge of common cardiac masses is vital to all radiologists, and here, we discuss the most pertinent imaging approach to cardiac masses emphasizing MR imaging.

Surgery for Cardiac Papillary Fibroelastoma: A 12-Year Single Institution Experience

BACKGROUND We reviewed our clinical experience with cardiac papillary fibroelastoma from 2005 to 2017. The objective of this study was to investigate the clinical and operative data, as well as the early survival rate and immediate postoperative complications. MATERIAL AND METHODS We performed a retrospective analysis of 11 patients (eight males and three females) who underwent resection of cardiac papillary fibroelastoma in our institution. RESULTS Mean age at tumor diagnosis was 60±14 years. The mean dimension of the tumor was 14±11 mm. The most common symptoms were dyspnea, palpitation, and angina pectoris, while one patient had recurrent fever attacks and another patient had a transient ischemic attack. Two patients had concomitant malignant tumors (cervical and colon carcinoma) and another two had concomitant benign neoplasms (liver cyst and thyroid adenoma). Bypass and cross clamp times were 77±32 minutes and 54±18 minutes, respectively. The tumors were found predominantly on cardiac valves (n=7). In eight cases, only tumor extirpation was performed, whereas in the other three cases, the valves had to be replaced. The mean intensive care unit length of stay was 1.1±0.3 days and there was no in-hospital mortality. All patients were alive at one-year follow-up and the survival rate was 91% in the mean follow-up period of 4.15 years. CONCLUSIONS The surgical treatment of cardiac papillary fibroelastoma was curative and safe. Thus, potential complications such as embolization or mechanical irritation of the valves can be avoided without high surgical risk.

Papillary fibroelastoma, unusual cause of stroke in a young man: a case report

BACKGROUND

Papillary fibroelastoma is the third most common primary benign tumor with an incidence of up to 0.33% in autopsy series; it accounts for approximately 75% of all cardiac valvular tumors.

CASE PRESENTATION

We describe a rare case of a 28-Year-old man that while playing football, had a sudden onset of neurological deficit: aphasia, right hemiparesis and right facial numbness. Transthoracic echocardiography (TTE) showed a 10x10 mm mass attached to the anterior mitral valve leaflet. The patient was treated surgically for the prevention of further embolic complications. Histologic examination of the resected mass revealed a papillary fibroelastoma. It is the third most frequent primary cardiac tumor, after myxoma and fibroma, and the most common primary tumor of heart valves. Despite the benign nature of this tumor, it carries very high risk of embolic complications. The successful complete resection of the papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.

CONCLUSIONS

Differential diagnosis of cardiac masses requires clinical informations, laboratory tests, blood cultures and appropriate use of imaging modalities. Papillary fibroelastoma is a potential cause of embolic stroke in the young. The prompt surgical excision of papillary fibroelastoma is curative and the long-term postoperative prognosis is excellent.

Lymphocyte-rich capillary-cavernous hemangioma of the mitral valve: a case report and review of the literature

Valvular hemangioma incidence is extremely low. In this report, we describe a 62-year-old man who presented with mild edema of the lower limbs. An echocardiogram revealed an incidental 1.3-cm diameter mass on the anterior mitral valve leaflet for which he underwent surgical resection and mitral valve replacement. Histopathological examination showed a lymphocyte-rich capillary-cavernous hemangioma. The exuberant lymphoid stroma is unusual for hemangioma and represents an undescribed pattern of cardiac hemangioma. Including the present report, only 13 cases of mitral valve hemangioma have been reported to date. Most patients are adult. Mitral hemangioma originates in the atrial aspect of the valve and involves more commonly the anterior leaflet. The average maximum diameter of the lesion is 1.7 (S.D.=0.75) cm. Pure cavernous hemangioma is the predominant type of mitral hemangioma. Most of them are described as pedunculated or polypoid. Surgical excision appears to be curative. Recurrences have not been reported. Lymphocyte-rich cardiac hemangioma represents a peculiar type of hemangioma which should be included in the differential diagnosis of other vascular lesions.

KRAS mutation in papillary fibroelastoma: a true cardiac neoplasm?

Primary cardiac tumours are rare and mostly benign lesions. Recent publications report that cardiac papillary fibroelastomas are the most common benign primary heart tumour, outnumbering myxomas. However, there is no consensus about their aetiology. We investigated the molecular profile of these tumours using next generation sequencing in a cohort of 16 cases. Eleven of 14 (79%) analysable tumours showed mutations of the KRAS oncogene. Our results provide unambiguous evidence that a significant proportion of these lesions are genuine neoplastic tumours caused by an oncogenic driver mutation.

Primitive Tumour of the Pulmonary Valve: Discussion of the Differential Diagnosis

There is a paucity of information concerning cardiac tumours of the pulmonary valve due to their rarity at this location. We report a case of a 47-year-old patient suffering from haemoptysis, asthenia, and acute kidney injury (AKI). A transthoracic echocardiography (TTE) revealed a mass on the pulmonary valve. Further diagnostic investigation was completed until he exhibited worsening hemodynamic instability. This case emphasizes the lack of information regarding the management of a pulmonary valve tumour.

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases

INTRODUCTION

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography.

OBJECTIVES

To describe the echocardiographic features of PFE and correlate them with the clinical presentation and initial treatment.

MATERIALS AND METHODS

A prospective analysis of patients with a diagnosis of PFE was conducted between 2000 and 2015. We assessed the clinical history, symptoms at the time of diagnosis, echocardiographic features, and initial treatment.

RESULTS

Fifty-four patients with a diagnosis of PFE by echocardiography were included. The incidence was 0.038%. Mean age was 62±16 years; 50% were male. Forty-six percent of patients had symptoms at the time of diagnosis, the most frequent of which was transient ischemic accident (TIA). Embolic episodes occurred in 31% of patients, mainly to the brain. PFEs were valvular in 70.4% of cases and multiple in 13%. Mean maximum length was 1.18±0.58 cm, and 44% were mobile. PFEs >1.5 cm were most often found in the heart valves (56.8% vs 10.8%; P=.045). There was no significant relation between size, mobility, location and number of tumors, and the presence of embolism or symptoms. Most frequent treatment was oral anticoagulation in 48.6%, followed by simple tumor resection in 42.8% of cases.

CONCLUSIONS

PFE is a small tumor, predominantly valvular and benign, but entails a high incidence of cerebral embolism. The initial approach should be individualized according to clinical manifestations, comorbidities, and the experience of the surgical center.

Cardiac Fibroelastoma versus Thrombus: Echocardiographic Evidence Can Be Misleading

We present a case of a young female with stroke symptoms who underwent valve sparing resection of a presumed fibroelastoma based on echocardiographic findings. After confirming embolic stroke, she underwent excision of the lesion, which on pathology revealed a nonbacterial thrombus. Ultimately, this led to a more extensive work-up leading to the discovery of a papillary serous ovarian carcinoma, the underlying cause of her hypercoagulable state. The initial echocardiographic findings painted the clear picture of a papillary tumor on the aortic valve which was likely the source of the emboli resulting in ischemic stroke. This unique case presentation illustrates that imaging, including echocardiography, may not always coincide with the clinical diagnosis. Thus, understanding the differential diagnoses of cardiac masses is of vital clinical significance. The distinction of fibroelastoma versus the much less common finding of aortic thrombus may lead to early diagnosis of malignancy and prevention of life threatening events due to stroke or undiagnosed disease.

Beating-heart surgical treatment of tricuspid valve papillary fibroelastoma: A case report

BACKGROUND

Cardiac papillary fibroelastomas are rare. And only 15% of the papillary fibroelastomas are located on tricuspid valve. However, the treatment of papillary fibroelastomas varies.

CASE SUMMARY

We report a 75-year-old Chinese male who was hospitalized because of a right atrial mass found by echocardiography. Complete tumor excision along with Kay's tricuspid valvuloplasty surgery on beating heart under cardiopulmonary bypass was performed to the patient. Pathologic examination confirmed the definite diagnosis of cardiac papillary fibroelastoma. The recovery of the patient was uneventful and echocardiographic examination performed 6 months after surgery revealed no recurrence of the tumor.

CONCLUSIONS

Beating-heart surgical excision is an effective and safe treatment of tricuspid papillary fibroelastomas.

Mitral Valve Myxoma

A 65-year-old man had a 6 × 4 × 4 cm myxoma adhering to the posterior leaflet of the mitral valve. He underwent successful myxoma resection and mitral valve replacement.

Surgical treatment of cardiac tumors: a 5-year experience from a single cardiac center

BACKGROUND

Cardiac tumors are rare but manifested with various clinical presentations and often cause unexpected symptoms or sudden death. The objective is to review the clinical presentation, histopathological spectrum, mortality and follow-up data of patients with cardiac tumors following surgery treatment over a period of 5 years.

METHODS

We retrospectively collected the medical records of all patients diagnosed of cardiac tumors in the period between January 2008 and December 2013 at the cardiac center of our university. Clinical histories, perioperative data, surgical findings, efficacy and follow-up data were reviewed in our study. Patients were divided into two groups according to site distribution of the tumors in the heart.

RESULTS

A total of 131 patients underwent surgical treatment of cardiac tumors were enrolled in this study, with a mean age of 51.39±16.37. The result of analysis showed that 79.47% (n=104) of the primary intracardiac tumors were benign, while primary malignant neoplasms accounted for 16.03% (n=21) of all patients, with the remainder (n=6, 4.6%) metastatic tumors transferred from other organs. Among all patients there were 2 in-hospital deaths and the survival rate in all patients at 1-year, 3-year and 5-year follow up was 83.20%, 78.62% and 66.41% respectively. Both patients with tumors in the left and right heart had similar basic characteristics except sex gender (P=0.002), BSA (P=0.045) and weight (P=0.033). Compared with patients with tumors in the right heart, patients with tumors in the left heart had significant higher CPB time (P<0.001), cross clamp time (P<0.001) and time of mechanical ventilation (P<0.001), and they also had longer ICU stay (P<0.001) but not total hospital stay (P=0.434).

CONCLUSIONS

Surgical resection represents an effective protocol in treating cardiac tumors. Data in our study of cardiac tumors on frequency and allocation were consistent with previous reports which may provide useful clinical evidence on shared data, and data revealed that patients with malignant cardiac tumors had significant lower survival both in hospital and long-term follow-up.

Surgical treatment of primary cardiac valve tumor: early and late results in eight patients

Background

To report early and late outcomes of patients with the primary cardiac valve tumor undergoing surgical treatment over a 30-year period in our cardiovascular center.

Methods

From January 1980 to December 2014, a total of 211 patients with primary cardiac tumors accepted surgical treatments, of which only 8 (3.8 %) were primary cardiac valve tumor patients in our surgical center of cardiovascular.

Results

The diagnosis was identified by echocardiography preoperatively and pathological analysis postoperatively. All patients underwent intracardiac procedures with extracorporeal circulation. Intracardiac procedures included resection of tumor on leaflet in 2 patients (25 %), resection of tumor and native valvuloplasty in 2 patients (25 %), resection of neoplasm and replacement of native valve with prosthetic valve in 4 patients (50 %). One man was performed a resection of tumor on aortic noncoronary leaflet and a coronary artery bypass graft. Eight cases of primary valve tumor occured in all of four cardiac valves. The majority of valvular tumor was myxoma in 3 cases (37.5 %), followed by the papillary fibroelastomas in 2 cases (25 %). There were one rhabdomyoma (12.5 %), one lipoma (12.5 %) and one mild malignant sarcoma (12.5 %). The mitral valve was the most commonly original valve (62.5 %). There was pulmonic (12.5 %), aortic (12.5 %) and tricuspid (12.5 %) valve tumor each one patient. There was no death and recrudescence in the series. Follow-up of all patients ranged from 1 to 16 years (mean 7.06±4.24 years). There was no recrudesce and cardiac valve dysfunction. 

Conclusion

The incidence of primary valve tumor was very low. More understanding of the rare disease and widespread use of echocardiography would greatly improve the diagnosis of primary valve tumor in the early stage. Echocardiography could detect millimeters in diameter neoplasms on cardiac valve. The diagnoses were based on imaging findings and the classical triad symptoms associated with the hemodynamic abnormalities, the organ embolism and the systemic symptoms directly from tumors. The intraoperative frozen sections and postoperative pathology analysis provided accurate diagnosis and supported the treatment strategies. Early diagnosis and intervention were keys to reserve the normal original valve function. Prompt surgical resection is necessary to prevent potential critical events.

Mitral degenerative disease mimicking a valvular tumor: a case report

Background

In rare cases, echo findings of degenerative valve disease is similar to valvular mass.

Case Presentation

A 56-year-old woman was evaluated for palpitation. Echocardiography revealed an 8- mm mass on the anterior mitral leaflet with minimal mitral insufficiency. Resection of the valve tumor was attempted to prevent a possible embolism. However, the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation. Triangular resection and ring annuloplasty were performed. The patient’s postoperative course was uneventful. Pathological examination revealeddegenerative disease.

Conclusions

This case illustrates that a valvular mass that looks like a tumor by echocardiography may actually be degenerative regardless of the presence of mitral insufficiency.