Papillary Fibroelastoma: Insight to a Primary Cardiac Valve Tumor

Diagnostic and Therapeutic Challenges Associated With Left Ventricular Tumors

Cardiac tumors are uncommon. Sometimes it is challenging to differentiate non-invasively between different kinds of cardiac tumors and thrombi, which is critical to dictate the subsequent treatment. In addition, not all high-risk cardiac tumors are amenable to surgical resection posing a therapeutic challenge. We report a case of cardiac papillary fibroelastoma in the left ventricular cavity with a 10-year follow-up, with no embolic complications.

Cardiac Papillary Fibroelastoma: Pulmonic Valve Involvement With Pulmonary Embolism and Pulmonary Hypertension

Papillary fibroelastomas are rarely seen tumors of the cardiac valves. We present a case of papillary fibroelastoma present on the pulmonic valve. Diagnosis was made by characteristic echocardiogram findings. Complications of pulmonary embolism and pulmonary hypertension were present. Due to contraindications, the patient was managed with anticoagulation instead of surgery. 

Left Atrial Fibroelastoma as a Cause of Stroke: A Case Report

Cardiac papillary fibroelastoma is a benign and rare primary tumor of the heart that is most frequently located in the aortic or the mitral valves. Papillary fibroelastoma arising from the left atrium is exceedingly rare, comprising less than 7% of all cardiac papillary fibroelastomas. Tumors in this location could be a source of cardioembolic stroke, often in the anterior circulation of the cerebrum. A 66-year-old female presenting with right hemiparesis, central facial palsy, homonymous hemianopia, and dysarthria received intravenous thrombolysis for stroke without apparent improvement. Magnetic resonance imaging of the brain revealed ischemic infarction in the territories of the left middle and posterior cerebral arteries. A tumor with a maximal diameter of 2.3 cm was disclosed during workup for possible cardioembolic stroke with transthoracic echocardiography and computed tomography of the heart. The clinical course was complicated by stroke-in-evolution and hemorrhagic transformation. The patient underwent left atrial tumor excision and left atrium appendage closure. In-patient stroke rehabilitation programs were also initiated after the conditions stabilized. No clinically significant complications developed after the operation. Neurological functions improved and the patient was able to perform most basic daily living activities with some assistance. An exhaustive search for the cause of cardioembolic stroke is paramount, as management strategies may differ from patients with thrombotic stroke.

Rare Cardiac Papillary Fibroelastoma: Right Atrial, Non-Valvular, Large, Symptomatic With Pulmonary Embolism

INTRODUCTION

Primary cardiac tumors are rarely seen in the general population and only a subset are classified as cardiac papillary fibroelastoma.

CASE PRESENTATION

A 59-year-old female that presented for unresponsiveness and cardiac arrest required 4 rounds of cardiopulmonary resuscitation and intubation. Laboratory investigations showed uncompensated respiratory acidosis, hyperkalemia, and elevated troponins. A chest computed tomography angiogram illustrated an acute right pulmonary embolism and a right atrial filling defect. Furthermore, an echocardiogram demonstrated a normal ejection fraction and a large, pedunculated, mobile, and non-valvular echodensity that was attached to the right atrium endocardium. Therefore, the patient was started on a heparin infusion and catheter-directed thrombolysis; however, the mass persisted. A surgical excision was performed, and a 40 mm was removed. The patient was diagnosed with a papillary fibroelastoma based on the clinical symptoms, imaging, and histological findings.

CONCLUSION

This patient's papillary fibroelastoma had multiple rare features including right atrial origin, large size, non-valvular location, and developed symptoms. Although this disease can be initially fatal, the patients typically have a favorable prognosis after a successful excision.

Successful interdisciplinary treatment of a rare cause of acute myocardial ischaemia from intermittent tumour-associated obstruction of the left main coronary artery: a case report

Background

A papillary fibroelastoma of the aortic valve has been reported as a rare cause of myocardial ischaemia. An advanced combined interventional and surgical approach leading to sufficient therapy for the patient is presented in this case report.

Case summary

A 56-year-old female patient presented in an emergency room of a hospital with an acute coronary syndrome. Over 1.5 years, recurrent stable angina had been known in the patient and significant coronary artery disease has already been ruled out in a previous coronary angiogram. The patient was immediately transferred to the catheter laboratory due to cardiogenic shock where a drug-eluting stent was implanted to, firstly, recanalize the left main coronary artery (LMCA) and, secondly, to protect the left main ostium from obstruction by an echocardiographic-proven mass. During subsequent deterioration of haemodynamics caused by decreasing left ventricular function and acute severe mitral insufficiency, firstly an intra-aortic balloon pump and secondly a veno-arterial extracorporeal membrane oxygenation was established through the femoral vessels. The patient was transferred to our cardiac surgery unit and was successfully operated utilizing a valve-sparing technique by extracting the tumour mass from the left coronary cusp and extracting the stent carefully from the LMCA. Histology revealed a papillary fibroelastoma.

Conclusion

A papillary fibroelastoma of the aortic valve with intermittent obstruction of the coronary arteries requires surgical therapy. Interventional recanalization and extracorporeal support might be useful strategies to ensure the patient’s safety as a bridge to surgery.

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.

Left Ventricular Papillary Fibroelastoma Presenting with Dyspnea on Exertion

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A patient presented with reduced effort tolerance and abnormal stress test.

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He was subsequently found to have a left ventricular mass.

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Multimodal imaging was utilized; however, diagnostic certainty remained limited.

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Cardiac surgery was pursued, wherein a single left ventricular mass was resected.

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Biopsy was consistent with cardiac papillary fibroelastoma.

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On follow-up, the patient reported a return to prior functioning.

Subaortic Membrane Papillary Fibroelastoma

A 61-year-old male presented for an annual exam and received a transthoracic echocardiogram (TTE) which revealed a mobile mass arising from a subaortic membrane. Further investigations with a transesophageal echocardiogram (TEE) and cardiac computerized tomography angiography (CTA) confirmed the presence of a mobile 9 mm × 3 mm mass on a subaortic membrane. Cardiothoracic surgery was performed with an open operation removing the mass and subaortic membrane. Upon visual inspection, the mass was likened to a sea anemone and immunohistochemical staining performed pathologically confirmed the diagnosis of cardiac papillary fibroelastoma. This case represents the first reported example of a cardiac papillary fibroelastoma (PFE) arising from a subaortic membrane. Although PFEs are benign cardiac tumors, proper identification and consideration for excision of these lesions may be indicated to prevent thromboembolic complications.

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.

Acute Myocardial Infarction in a Patient with Two-Vessel Occlusion and a Large Lambl's Excrescence

A 59-year-old man underwent an echocardiography study after myocardial infarction and it showed a thin, mobile mass attached to the aortic valve. A diagnosis of Lambl's excrescence (LE) was suspected. Coronary occlusion as a consequence of embolism of LE's material could not be excluded and the patient underwent surgical excision. Histology confirmed the diagnosis; however a differential diagnosis with papillary fibroelastoma could not be established because both of these structures are histologically indistinguishable. A brief survey of the literature is presented. Evidence-based recommendations for treatment have not been established yet.

Use of microbubble contrast in the diagnosis of a left ventricular papillary fibroelastoma

A papillary fibroelastoma is a rare, avascular, cardiac tumour that is often found incidentally using transthoracic echocardiography (TTE). Peripheral i.v. injection of a microbubble contrast agent is often used to characterize abnormal masses within the heart allowing further delineation of physical features, the area of attachment, and vascularity of the mass in order to differentiate the growth from a tumour or a thrombus. This case highlights a potential pitfall when assessing a cardiac tumour's vascularity using contrast TTE. A cardiac mass was identified on a TTE of a 53-year-old man and was further investigated with microbubble contrast-enhanced TTE. Contrast TTE imaging suggested a vascularized structure in the left ventricle. However, after histological examination the tumour was found to be entirely avascular.

Lambl's Excrescences: Association with Cerebrovascular Disease and Pathogenesis

BACKGROUND

Lambl's excrescences (LEx) are detected by transesophageal echocardiography (TEE) and are characterized as thin, elongated, and hypermobile structures located at the leaflets' coaptation point of the heart valves. The association of LEx with cerebrovascular disease (CVD) is still undefined and yet patients with LEx and suspected CVD receive unproven effective antiplatelet or anticoagulant therapy or even undergo valve surgery. Also, the association of LEx with aging and atherogenic, inflammatory, or thrombogenic parameters has not been reported.

METHODS

Seventy-seven patients with systemic lupus erythematosus (SLE) (71 women, age 37 ± 12 years) and 26 age- and sex-matched healthy controls (22 women, age 34 ± 11 years) prospectively underwent routine history and physical exam, transcranial Doppler, brain MRI, TEE, carotid duplex, and clinical and laboratory evaluations of atherogenesis, inflammation, platelet activity, coagulation, and fibrinolysis. Subjects without stroke/TIA on enrollment (with and without LEx) had a median follow-up of 57 months.

RESULTS

On enrollment, 33 (43%) of 77 patients had CVD manifested as acute stroke/TIA (23 patients), cerebromicroembolism by transcranial Doppler (17 patients), or cerebral infarcts by MRI (14 patients). Mitral or aortic valve LEx were equally frequent in healthy controls (46%) as in patients with and without any CVD (39 and 43%), stroke/TIA (35 and 43%), cerebromicroembolism (41 and 42%), or cerebral infarcts (36 and 43%) (all p ≥ 0.72). Also, other mechanisms for CVD other than LEx such as Libman-Sacks vegetations, patent foramen ovale or interatrial septal aneurysm, aortic or carotid atherosclerosis, or thrombogenesis were found in ≥94% of patients with CVD. In addition, 36 subjects with and 44 without LEx had similar low incidence of stroke/TIA (1 (1.3%) and 2 (2.5%), respectively, p = 1.0) during follow-up. Finally, LEx were not associated with aging, atherogenic risk factors, atherosclerosis, inflammation, or thrombogenesis.

CONCLUSIONS

In this study, LEx are similarly prevalent in healthy controls and SLE patients, are not associated with CVD, and are not associated with pathogenic risk factors. Therefore, the study findings suggest that LEx may not be cardioembolic substrates, may not represent pathologic valve structures, and may not require therapy.

Cardiac tumors--diagnosis and surgical treatment

BACKGROUND

Primary tumors of the heart are rare even in major cardiac surgery centers. Because of the low case numbers, there is an insufficient evidence base to determine the optimal treatment, particularly for malignant tumors.

METHOD

The authors review the pertinent literature retrieved by a selective PubMed search on the terms "cardiac tumor," "heart tumor," "cardiac myxoma," and "cardiac sarcoma." They also present operative techniques and their own long-term results in 181 patients with cardiac tumors.

RESULTS

Patients with cardiac tumors generally have nonspecific symptoms depending on the site of the tumor and the extent of infiltration into the neighboring tissue. The diagnosis is based on the clinical history, echocardiography (in most cases), and, sometimes, computerized tomography and magnetic resonance imaging. Autopsy studies reveal a 0.02% prevalence of cardiac tumors, of which 75% are benign and 25% malignant. Myxoma is the most common benign tumor (50-70%); angiosarcoma is the most common malignant one (30%), followed by rhabdomyosarcoma (20%). About 10% of all tumor patients develop cardiac metastases, but these are only rarely clinically manifest. From 1989 to 2012, 181 patients underwent surgery for cardiac tumors in the authors' institution. The 5-year survival rates were 83% for benign tumors (139 patients), 30% for malignant tumors (26 patients), and 26% for cardiac metastases (16 patients).

CONCLUSION

Patients with cardiac tumors should undergo surgery in a timely fashion in a specialized center. This holds for both malignant and benign tumors, particularly for atrial myxoma, which can cause serious secondary complications by embolization.

Mechanical endovascular procedure for the treatment of acute ischemic stroke caused by total detachment of a papillary fibroelastoma

Papillary fibroelastomas (PFEs) are rare cardiac tumors. Despite their benign nature, they are associated with a high risk of embolic complications including stroke. Endovascular treatment has been reported as a safe procedure in patients with myxoma, the most common type of primary cardiac tumor. A case of ischemic stroke due to embolization of a PFE successfully treated with a single pass of a retrievable stent is described. A 64-year-old patient with a right middle cerebral artery syndrome was treated with an intravenous and endovascular protocol as a revascularization procedure. Mechanical thrombectomy resulted in total recanalization with clinical improvement. Histological examination of the clot showed pathological features of a typical PFE. The endovascular treatment was safe and effective. With mechanical embolectomy it is possible to obtain and analyze pathological specimens, enabling the diagnosis of uncommon strokes.

Transmitral resection of a left ventricular apical papillary fibroelastoma using video-assisted thoracoscopy

Papillary fibroelastomas (PFEs) are rare benign tumors usually found on cardiac valves, and do not commonly originate from the left ventricle (LV). We report a 74-year-old female with a PFE in the LV apex. We performed complete resection of the tumor through a transmitral approach using video-assisted thoracoscopy.

Video-assisted resection of papillary fibroelastoma arising from a miniature tendinous chord in the apex of the left ventricle

We report a rare case of a papillary fibroelastoma (PFE) in the apex of the left ventricle.An 81-year-old woman with nonspecific symptoms was shown to have a mobile mass deep in the left ventricle. With videoscopic assistance, removal of the mass was accomplished through the mitral valve via a midline sternotomy under cardiopulmonary bypass. The tumor arose from a miniature tendinous chord in the apex, and histological examination revealed PFE. Videoscopy facilitated safe and effective removal of the lesion in this case.

Multiple papillary fibroelastomas of the aortic valve detected by real time three-dimensional transesophageal echocardiographic images

Papillary fibroelastoma (PFE) is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that were clearly demonstrated and evaluated with real time three-dimensional (RT3D) transesophageal echocardiography (TEE). A 77-year-old woman was referred to our institution with a diagnosis of osteoarthritis of the hip. Transthoracic echocardiography showed an abnormal structure on the aortic valve. Although two-dimensional TEE revealed typical characteristics of multiple PFE, RT3D TEE clearly demonstrated their number and location on the right and non-coronary cusp of the aortic valve. These results were subsequently confirmed by surgery and pathological findings. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE. <Learning objective: PFE is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that was clearly demonstrated and evaluated with RT3D TEE. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE.>.

Papillary fibroelastoma mimicking vegetation of the mitral valve

Although cardiac papillary fibroelastoma is rare, it is the most common primary tumor of cardiac valves. The clinical presentation of these tumors varies from asymptomatic to embolic complications. We report an asymptomatic case of papillary fibroelastoma of mitral valve which was diagnosed by transthoracic echocardiography. The tumor was successfully resected by surgery.

Surgical experience with cardiac papillary fibroelastoma over a 15-year period

BACKGROUND

Papillary fibroelastomas are rare, benign cardiac tumors. They are predominantly asymptomatic. However, they can lead to serious complications, namely thromboembolic events. Symptomatic lesions can be managed primarily with surgical excision and valvular preservation. Controversy exists as to the management of asymptomatic lesions.

METHODS

All patients diagnosed with cardiac papillary fibroelastoma between 1996 and 2012 at a single institution were queried for clinical and pathologic characteristics.

RESULTS

Twenty-three patients with 29 lesions were identified. Most lesions were solitary, less than 1.0 cm in diameter, and occurred in patients greater than 60 years of age. The most common presentation was thromboembolic complication. All were managed successfully with surgical excision. One patient developed a recurrence or metachronous lesion within 3 months of initial surgical intervention.

CONCLUSIONS

Papillary fibroelastomas are rare, benign, predominantly asymptomatic cardiac tumors that can cause potentially serious complications. The natural history and etiology of papillary fibroelastomas are largely unknown. Controversy exists over the management of asymptomatic lesions. However, there is consensus that symptomatic lesions should undergo surgical excision with valvular preservation when possible. A unique case of a possible papillary fibroelastoma recurrence is also described.

Papillary fibroelastoma of the aortic valve with atypical chest pain: late presentation with acute myocardial infarction and cardiac arrest

We report a case of a 54-year-old female with papillary fibroelastoma of the aortic valve who presented with ST-elevation myocardial infarction and cardiac arrest. Though her initial symptom was only atypical chest pain, life-threatening complications such as acute myocardial infarction and cardiac arrest developed. After cardiopulmonary resuscitation, we promptly resected the fibroelastoma on cardiopulmonary bypass, and the patient was discharged without any other complications.

Environmental Pollution as a Cause of Papillary Fibroelastoma: Hints for a New Etiological Hypothesis?

<p><b>Background:</b> Environmental pollution has adverse human health effects, mostly on the respiratory tract but also on the cardiovascular system. Papillary fibroelastomas are exceedingly rare primary cardiac tumors; their pathologic origin remains still elusive.</p><p><b>Case Report:</b> This is a brief report on 3 patients referred for surgical treatment of papillary fibroelastomas in the last 6 months. All patients were born, lived, and worked in a narrow region in Campania that is under active monitoring because of high rates of environmental pollution.</p><p><b>Conclusions:</b> Known mechanisms of cardiovascular damage generated by environmental pollution are cross linked with described papillary fibroelastomas' etiological cascade. Evidence is suggested for a common origin. These results provide intriguing but inconclusive insights into pathophysiological pathways that may link exposure to environmental pollution and development of papillary fibroelastomas.</p>