Unusual place… unusual number

Cardiac papillary fibroelastoma is a rare, benign cardiac tumor. It often arises from the valvular endocardium and is usually solitary. Nonvalvular location is rare and even more rare is the presentation as multiple masses. A 71-year-old female patient was referred for echocardiographic evaluation due to progressive fatigue. The presence of multiple left atrial masses was observed on echocardiographic evaluation. The patient was treated surgically for the prevention of embolic complications, and the histologic diagnosis of multiple nonvalvular papillary fibroelastoma was made. This case highlights the need to consider this unusual location and presentation for this type of tumor.

Cardiac papillary fibroelastoma arising from the opening of the left inferior pulmonary vein in left atrium: A rare case report

RATIONALE

Cardiac papillary fibroelastoma is a small, benign endocardial tumor, while it is clinically important because of its strategic position and propensity for causing embolic events and hemodynamic complications.

PATIENT CONCERNS

A 59-year-old female presented our hospital for investigation and treatment of a sudden onset of syncope lasted about 2 minutes.

DIAGNOSES

Cardiac papillary fibroelastoma arising from left inferior pulmonary vein in left atrium.

INTERVENTIONS

The tumor was successfully removed by cardiac surgery.

OUTCOMES

The patient's postoperative course was uneventful, and she was discharged 10 days after surgery. The patient remained free of neurologic deficits and had no evidence of residual or recurrence of tumor with echocardiography during 1 year of follow-up.

LESSONS

Cardiac papillary fibroelastoma is a benign tumor, with increased risk of thromboembolic events. It is often diagnosed in patients with echocardiography by chance or after a neurologic event. Complete surgical resection should be considered when the patient is indicated and the long-term postoperative prognosis is excellent.

Incidental finding of an asymptomatic pulmonary valve papillary fibroelastoma: A case report

Primary cardiac tumors are rare, but papillary fibroelastoma (PFE) is reportedly the most common form, which usually occurs on the left-side valves of the heart. However, PFE involving the tricuspid and pulmonary valves has also been documented. Although PFE is benign and seldom associated with valvular dysfunction, the associated embolic complications may lead to serious consequences. Most patients with PFE lack specific clinical symptoms and the diagnosis is incidental. Surgical resection is the mainstay treatment for PFE in order to prevent the occurrence of embolic complications. In this report, we present a case of a rare asymptomatic PFE of the pulmonary valve, which was incidentally noted during a routine examination with transthoracic echocardiography (TEE). There was neither valvular dysfunction nor hemodynamic change. The PFE was surgically removed, and the diagnosis was further confirmed with histopathology.

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.).

Papillary fibroelastoma in the left atrium

Described herein is a 71-year-old woman with previous angina pectoris who suddenly developed slurred speech and right-arm weakness. She was found to have significant coronary narrowing, a small mass in the left atrium attached to the endocardium near the orifice of the appendage, and multifocal punctate cerebral lesions in the distribution of the left middle cerebral artery. The left atrial mass was excised and confirmed to be a papillary fibroelastoma. Coronary bypass was also performed. It is believed that fibrin thrombus developed within the fronds of the fibroelastoma and embolized to the brain. Such lesions in the left atrium are exceedingly uncommon. She had no further emboli events.

Cerebral Embolism due to a Large Papillary Fibroelastoma arising from the Coumadin Ridge

A 70-year-old woman developed acute cerebral infarction. Transthoracic echocardiography showed a large mobile mass in the left atrium, suggesting cardiac myxoma as the most likely diagnosis. Surgical exploration revealed a papillary fibroelastoma originating from the coumadin ridge, which is fairly rare but important as a source of cerebral embolization.

Papillary Fibroelastoma of the Left Ventricle in a Radiation-treated Cancer Patient

We present the case of a 69-year-old female patient with a history of endometrial carcinoma in 1996, who underwent a total hysterectomy and bilateral adnexectomy. The patient also received chemotherapy and mediastinal radiotherapy followed by cancer remission. Ten years later she presented with heart failure and her Doppler-echocardiogram showed severe mitral regurgitation with pulmonary hypertension and a papillary fibroelastoma in the left ventricle. In 2011, she underwent a mitral valve replacement with a biological prosthesis and the pathology exam revealed valve damage consistent with radiotherapy- induced changes and confirmed the presence of a papillary fibroelastoma. This unusual mechanism of papillary fibroelastoma should be disseminated among cardiology physicians and in patients who have survived for long periods after radiotherapy. It is important to remember that cardiac complications may indeed occur, and the treating physician is responsible for detecting them.

Pulmonary Eosinophilic Inflammatory Infiltration Post-Intensive Care in a Nearly Drowned Young Man with Papillary Fibroelastoma: A Rare Complication Discovered by Forensic Autopsy

Papillary fibroelastoma is a rare benign lesion of heart (1). It is the second most common primary cardiac neoplasm, accounting for 4.4-8% of all tumors of the heart (2). We described a forensic autopsy of a nearly drowned young man with cardiac papillary fibroelastoma who died because of a pulmonary inflammatory infiltration rich in granulocytes after intensive care. This occurrence is rare but possible and should be kept in mind because a lung inflammatory infiltrate rich in eosinophilic granulocytes can be present in different pathological conditions and differential diagnoses are often difficult to do.

An aortic valve papillary fibroelastoma: A case report

Papillary fibroelastomas are rare tumors of the heart, mostly involving the valves. They can be asymptomatic and diagnosed incidentally or they can cause life-threatening clinic scenarios including cerebrovascular accidents, coronary arterial occlusions, or peripheral embolisms. Papillary fibroelastomas can be easily excised surgically using valve sparing techniques with low complication rates and without recurrence. In this report, we present a case of papillary fibroelastoma which was found incidentally before coronary artery bypass grafting operation and successful removal of the lesion with a valve sparing approach.

Histology of Thrombectomy Specimen Reveals Cardiac Tumor Embolus in Cryptogenic Young Stroke

A 25-year-old woman presented with acute onset of right hemiplegia and global aphasia with National Institutes of Health Stroke Scale score of 19. Computed tomography angiography demonstrated occlusion of the left proximal middle cerebral artery. She was thrombolysed with intravenous recombinant tissue plasminogen activator (0.6 mg/kg) within 3 hours of onset of symptoms and was taken up for mechanical thrombectomy. The retrieved specimen appeared pale white and soft; histopathologic examination revealed a papillary neoplasm composed of papillae with hyalinized cores lined by endothelium, consistent with papillary fibroelastoma of cardiac origin. Transesophageal echocardiography showed no abnormalities, which can be explained by complete embolization of the mass into the cerebral circulation. On follow-up after 5 months, the patient recovered with only minimal aphasia and no cardiac symptoms. Our experience with this case highlights the importance of histopathologic examination of the mechanical thrombectomy specimen, as it provided the only clue to the etiology of stroke.

Papillary Fibroelastoma Found With Transesophageal Echocardiography After a Normal Transthoracic Echocardiography

We present the case of a patient with transient ischemic attacks who was being investigated for multiple embolic strokes. Initial workup, including brain computed tomography, computed tomography angiography, and transthoracic echocardiography (TTE) were negative for a source until transesophageal echocardiography (TEE) found a mass in the left atrium. The TEE differentiated the mass as a rare cardiac papillary fibroelastoma on the left atrial free wall confirmed by postsurgical pathology. This case highlights the importance of TEE as a diagnostic tool for its ability to more accurately differentiate and characterize the tumor compared with TTE. This case underscores that a negative TTE does not equate to zero risk of the presence of a cardiac tumor. It is prudent for the clinician to be cognizant that it may be beneficial to perform a TEE even with a negative TTE workup.

Aortic valve replacement for papillary fibroelastoma

Surgery is indicated for symptomatic patients with papillary fibroelastomas (PFE) on the aortic valve. The valve is commonly spared during tumor excision. Rarely, aortic valve replacement (AVR) is needed. We present a case requiring AVR for an aortic valve PFE and review the literature to determine the risk factors for failure of aortic valve-sparing techniques in patients with PFE.

Incidental tricuspid valve fibroelastoma associated with patent foramen ovale in a young female: Straightforward diagnosis but controversial management

Papillary fibroelastoma is an uncommon primary cardiac tumor, predominantly associated with left-sided valvular endocardium. Affectation of tricuspid valve leaflets is rare, and management in asymptomatic patients remains controversial. We present a 30-year-old female referred for evaluation prior to bariatric surgery. A routine echocardiogram revealed a mobile cardiac mass attached to the tricuspid valve. A patent foramen ovale was also present. Tumor was surgically removed. Histology confirmed the definite diagnosis of a papillary fibroelastoma. In our case, the presence of a patent foramen ovale associated with the right-sided fibroelastoma was decisive in the decision for surgery.

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.

[Papillary fibroelastoma: retrospective analysis. Clinical presentation and surgical results]

Papillary ibroelastomas are small benign intracardiac tumors known for their embolic potential. Since the introduction of echocardiography with improved resolution and transesophageal imaging techniques, they are being increasingly detected in clinical practice. In recent series, papillary fibroelastoma is considered the most frequent benign tumor of the heart. Our objective was to analyze characteristics and midterm surgical outcome of histologically-confirmed cases of papillary fibroelastoma. We conducted a retrospective study on patients with cardiac tumors submitted to surgical excision between June 1992 and February 2017. Out of 108 patients, 18 had papillary fibroelastomas. Their mean age was 58 years (22-77); 10 were men. The most frequent localizations were the aortic valve (7) and the mitral valve (5). None had significant valvular dysfunction. By transesophageal echocardiography, the tumor size (larger diameter) was 13.33 ± 5.55 mm (6.6-28.0). Two patients, both with tumor in the aortic valve, had suffered a stroke; other two had dyspnoea and atrial flutter, respectively. The remaining 14 patients were asymptomatic and their tumors were incidental findings. In 15 patients the valve was preserved. There was neither surgical mortality nor recurrence after 2.6 years of follow-up. In conclusion, most papillary fibroelastomas can be surgically removed with valve preservation and favorable clinical outcome. However, until the results of randomized trials support the decision, an aggressive surgical approach in asymptomatic patients needs to be defined in the context of surgical expertise.

Video-assisted endoscopic resection of left ventricular papillary fibroelastoma through the aortic valve

Papillary fibroelastoma is a rare, benign cardiac tumor. Surgical resection is indicated to prevent embolization. We herein report a case of a 78-year-old asymptomatic man who was found to have a mobile left ventricular papillary fibroelastoma anchoring deep in the left ventricle by incidental transthoracic echocardiography. The tumor was resected under visualization by a video-assisted rigid endoscope with a flexible head inserted through the aortic valve into the left ventricle. Intraoperative frozen section analysis provided a pathological diagnosis of papillary fibroelastoma. The postoperative course was uneventful. This technique is recommended for the observation and resection of a tumor anchoring deep in the left ventricle and is helpful for avoiding the adverse effects of left ventriculotomy.

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.

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.

Non-exophytic Lambl excrescences of aortic valves: a morphological study

AIMS

To elucidate the histopathological findings of classical Lambl excrescences (LEs) and non-exophytic LEs (non-ex LEs) without excrescent papillary features.

METHODS AND RESULTS

We examined 126 aortic valves (AVs) and revealed LEs (non-ex and/or classical), non-ex LEs and classical LEs in 106, 78 and 88 AVs, respectively. The detection of non-ex LEs was challenging, but elastica van Gieson stain highlighted their presence. Non-ex and classical LEs chiefly involved the ventricular regions, favoured posterior cusps and coexisted in the same areas of 31 AVs. A possible transformation of classical LEs into non-ex LEs was suggested histologically in 39 AVs. Non-ex LEs were associated with age of >70 years (P < 0.001) and marked deformity (P = 0.007). Classical LEs were associated inversely with marked deformity (P < 0.001), but not with age of >70 years. Compared with age- and sex-matched control AVs, non-ex LEs and marked deformity in dysfunctional AVs were more common (P = 0.037 and P < 0.001, respectively), but classical LEs were less common (P = 0.021).

CONCLUSIONS

Non-ex LEs have subtle features but are a common form of LEs, and seem to develop from classical LEs. AV dysfunction-related marked deformity can promote non-ex LEs.

A case of a fibroelastoma and patent foramen ovale in a patient with prior stroke

We describe the case of a patient who underwent patent foramen ovale (PFO) closure for secondary stroke prevention. On routine follow-up transesophageal echocardiography (TEE), a papillary fibroelastoma was identified and removed successfully surgically. The fibroelastoma had not been recognized during preprocedural imaging and escaped our attention during limited intraprocedural transesophageal echocardiographic imaging (focusing on the interatrial septum) given the small size and visualization requiring thorough imaging in multiple planes and modified views. Our case illustrates the importance of detailed echocardiographic imaging prior to PFO device implantation; otherwise, subtle concomitant and at least equally probable causes of stroke can be overlooked.

Papillary fibroelastoma of the pulmonary valve--a systematic review

The pulmonary valve is the least affected site for valvular papillary fibroelastoma. With increasing use of routine echocardiography and other modalities of imaging, pulmonary valve papillary fibroelastomas (PVPFE) are being recognized more frequently. PVPFE is more often an incidental diagnosis and symptomatic patients usually present with shortness of breath. Embolic phenomena and right ventricular outflow tract obstruction are the most serious complications of PVPFE. Since PVPFE is rare, the purpose of this systematic review is to address demographic characteristics, the clinical presentation, management, and outcome of this benign tumor of the pulmonary valve.

Multiple causes for an ischemic stroke: myxoma, papillary fibroelastomas and patent foramen ovale

We report a case in which multiple uncommon causes of an ischemic vascular accident coexisted in the same patient. The patient was admitted with signs of acute stroke. Investigation workup revealed a left atrial tumor (myxoma) and a patent foramen ovale. Intraoperatively, transesophageal echocardiography added new information: papillary fibroelastomas were found in the aortic valve. This finding dictated a change in the surgical plan, adding resection of aortic valve masses to the planned excision of the left atrial tumor and patent foramen ovale closure. The uniqueness of this case derives from the coexistence of rare primary cardiac tumors. There are only five cases in literature of myxoma concomitant with fibroelastoma and the occurrence of multiple fibroelastoma is also extremely rare. Moreover this case emphasizes the benefit of the intraoperative use of transesophageal echocardiography to improve the diagnosis and management of cardiac surgical patients.