Cardiac papillary fibroelastoma

Papillary fibroelastoma of the left atrial appendage: echocardiographic findings

Papillary fibroelastoma is a small and rare benign intracardiac tumor that most frequently arises from the valvular endocardium. We report a patient with acute myocardial infarction in whom a papillary fibroelastoma in the left atrial appendage was detected by a transesophageal echocardiography during evaluation of the myocardial infarction. The roles of transesophageal echocardiography and surgical intervention are discussed.

Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation

Primary cardiac and pericardial neoplasms are rare lesions and include both benign and malignant histologic types. Myxoma is the most frequent primary cardiac neoplasm, but other benign tumors include papillary fibroelastoma, rhabdomyoma, fibroma, hemangioma, lipoma, and paraganglioma. Cardiac sarcoma represents the second most common primary cardiac neoplasm. Lymphoma can also affect the heart primarily. Pericardial tumors that affect the heart include benign teratomas and malignant mesotheliomas. Patients affected with cardiac or pericardial neoplasms often present with cardiovascular compromise or embolic phenomena and exhibit cardiomegaly at chest radiography. Benign cardiac tumors typically manifest as intracavitary, mural, or epicardial focal masses, whereas malignant tumors demonstrate invasive features and may involve the heart diffusely. Benign lesions can usually be successfully excised, but patients with malignant lesions have an extremely poor prognosis.

Papillary fibroelastomas

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

Unusual primary tumors of the heart

Primary tumors of the heart, with the exception of atrial myxomas, occur rarely; tumors metastatic to or directly invasive of the heart are far more common. About 75% of primary tumors are benign, and 75% of these are atrial myxomas. The benign tumors include rhabdomyomas, fibromas, papillary fibroelastomas, hemangiomas, pericardial cysts, lipomas, hamartomas, teratomas, mesotheliomas, and paragangliomas or pheochromocytomas. The last 3 may also be malignant. The malignant tumors consist of various sarcomas: myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, undifferentiated sarcoma, reticulum cell sarcoma, neurofibrosarcoma, and malignant fibrous histiocytoma. Cardiac tumors produce a large variety of symptoms through any of 4 mechanisms. Their mass can obstruct intracardiac blood flow or interfere with valve function. Local invasion can lead to arrhythmias or pericardial effusions with tamponade. Bits of tumor can embolize, causing systemic deficits when the tumors are on the left side of the heart. Finally, the tumors may cause systemic or constitutional symptoms. Some tumors, of course, produce no symptoms and become evident as incidental findings. The most useful diagnostic tool is the echocardiogram, which in almost all cases precisely locates the tumor and defines its extent. The echocardiographic appearance may also allow quite accurate prediction of the tumor type and whether it is malignant or benign. Magnetic resonance imaging serves as the next most important test where the density of T1 and T2 images may allow tumor cell type identification. With few exceptions, these tumors require operative excision. Most benign tumors can be resected completely; a few, because of their large size, cannot be, and only tumor debulking may be possible. Heart transplantation should be considered for these patients. Many of the malignant tumors cannot be resected completely, either because of the extent of local spread and invasion or because of the frequent distant metastases. Transplantation may also be an option for those with extensive local disease. The long-term results for resected benign tumors are excellent; the long-term results for sarcomas are very poor, and there are few survivors. For patients with unresectable sarcomas, radiation and chemotherapy may be used, but without great expectation of successful results.

Papillary fibroelastoma of the mitral valve with systemic embolization

Primary tumors of the heart are rare disorders. In autopsy studies, their incidence was reported to be 0.01-0.5%. We present the case of a papillary fibroelastoma of the mitral valve with systemic embolization in a young man.

A cardiac papillary fibroelastoma with chordal location

Papillary fibroelastomas, which were initially incidental findings at autopsy and surgery, are now being recognized with increasing frequency with the widespread use of echocardiography. Because of their embolic potential, an aggressive treatment approach is generally accepted. We report a papillary fibroelastoma located at the chorda of the anterior mitral leaflet that underwent conservative follow-up for 8 years without any complications. Because most of the cardiac papillary fibroelastoma cases reported are incidental findings, the question of whether symptomless fibroelastomas must be removed or other factors contribute to the embolic nature of the selected cases remains a challenge for the future.

Papillary fibroelastoma: increasing recognition of a surgical disease

Papillary fibroelastomas are uncommon benign tumors usually involving the heart valves, which historically have been diagnosed at autopsy. With the advent of echocardiography, however, the number of patients diagnosed in life has increased. Papillary fibroelastomas represent a surgically treatable cause of cerebrovascular and cardiovascular ischemia and infarction making their identification clinically important. We report three unusual cases of papillary fibroelastoma; two patients presenting with symptoms of cerebrovascular ischemia and one presenting with myocardial infarction. We also present a comprehensive review of the literature and provide a compilation of all case reports to date.

Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization

OBJECTIVE

We have reviewed the case histories of 4 patients who underwent operations between September 1994 and November 1997 at Broussais Hospital for cardiac valvular papillary fibroelastoma.

METHODS

Diagnosis was strongly suggested by echocardiography. Tumor locations were mitral (1), tricuspid (1), and aortic (2). Indications for operation were previous stroke for the mitral tumor, prophylaxis for the tricuspid tumor, syncopal episodes for the first aortic tumor, and transient ischemic attack and mesenteric ischemia for the second aortic tumor.

RESULTS

Surgical excision with a conservative, valve-sparing approach was performed in all cases. For the first aortic tumor, aortic valve reconstruction was achieved with part of a cryopreserved aortic homograft cusp. Intraoperative transesophageal echocardiography showed no evidence of valvular regurgitation after excision in all cases. All patients had uneventful postoperative recoveries. No evidence of regurgitation or recurrence was seen on echocardiography at follow-up.

CONCLUSIONS

Despite their histologically benign aspect, cardiac papillary fibroelastomas should be excised because of potential embolic complications. A conservative, valve-sparing approach is recommended, however, because of the absence of recurrence after total excision.

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

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

Cardiac papillary fibroelastoma of the mitral valve chordae

Papillary fibroelastomas are rare, benign, primary cardiac tumors, usually single and small. The neoplasm consists of a leafy, soft excrescence typically located on the cardiac valves. Although papillary fibroelastomas are usually an asymptomatic incidental finding at autopsy, or during cardiac operation, they are occasionally associated with embolic coronary or cerebral symptoms. A case of a patient is reported with papillary fibroelastoma of the mitral valve chordae, who presented several transitory ischemic attacks characterized by loss of conscience, visual bilateral deficit and right emiparesis. Because of their potential systemic embolization, we believe that these lesions should be always excised.

Evolution of a papillary fibroelastoma

Papillary fibroelastoma is a rare primary tumor of the heart usually found incidentally at autopsy. Little is known about the natural history of this tumor, but an aggressive surgical approach is recommended because of the high incidence of embolization. We describe a patient whose tumor was found during transthoracic echocardiography and who had had a normal echo 10 years previously. This finding suggests that papillary fibroelastoma may be an acquired rather than a congenital lesion.

Echocardographic features of papillary fibroelastoma and their consequences and management

Thirty-five percent of patients (5 of 15) were diagnosed with ischemic stroke from left-sided papillary fibroelastomas by diagnosis of exclusion, whereas 40% of patients (6 of 15) did not have ischemic stroke.

Rapid Development of a Papillary Fibroelastoma with Associated Thrombus: The Role of Transthoracic and Transesophageal Echocardiography

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are frequently utilized in patient's with suspected cerebral vascular ischemia. We describe a patient with suspected cerebral vascular ischemic event whom was found to have a mobile valvular mass by TTE and TEE. The lesion was unusual due to its rapid development over a period 6 months, which was documented on serial echocardiography. The mass was excised surgically and pathology showed a papillary fibroelastoma with extensive thrombus. The differential diagnosis of a cardiac valvular mass and the treatment of cardiac fibroelastomas are reviewed. In this case, both TTE and TEE were valuable in diagnosis and facilitating surgical management of a cardiac fibroelastoma.

Papillary fibroelastoma of the tricuspid valve in association with an atrial septal defect: report of a case

Although papillary fibroelastoma is rare, it is the most common primary tumor of the heart valves. We describe herein the case of a 64-year-old woman scheduled to undergo atrial septal defect (ASD) repair, in whom a papillary fibroelastoma of the tricuspid valve was diagnosed by transesophageal echocardiography (TEE). Surgical resection of the papillary fibroelastoma at the time of ASD repair prevented the fatal embolization sometimes associated with this lesion. Thus, intraoperative TEE played an important role in identifying the location of the tumor and its anatomic attachment, and in assessing the adequacy of surgical treatment.

Excision of papillary fibroelastoma arising from the septal leaflet of the tricuspid valve

A case of a papillary fibroelastoma (PFE) arising from the tricuspid valve was reported. It was incidentally detected by two-dimensional transthoracic echocardiography. Prior to 1977, these tumors were exclusively found at postmortem examination. This is only the fourth reported case of a tricuspid valve PFE found by echocardiography, treated by excision, and with tricuspid valvuloplasty preserving the native valve.