Cardiac papillary fibroelastoma and stroke. Echocardiographic diagnosis and guide to excision

Genetic insights into cardiac tumors: a comprehensive review

Cardiac neoplasms are rare, however, also a curable form of the disease once detected early. In recent years the viscus tumors have gained their highlights, due to the advancement in techniques like echocardiography both 2D and 3D, MRI, etc. These cardiac tumors are divided based on their benign and malignant nature and also as well as primary and secondary cardiac tumors. Largely the primary cardiac tumors are often than secondary cardiac tumors. The secondary tumor happens anywhere in the body involving the heart. The most common malignant tumors are sarcoma, some are angiosarcomas, fibromas, rhabdosarcoma, and leiomyosarcoma. The primary sarcoma affects both men and women at an equal rate with non-specific symptoms. These conditions led to high demand in genomic testing that helps in spot the mutation that leads to the particular type of cardiac neoplasm and it additionally helps to screen the mutated sequence and stop it from being inherited. Recent studies on cardiac tumors have revealed many genes that are involved in tumorigenesis and technologies have enabled the right screening of the tumor location within the heart and their histopathological studies were also studied. This review principally focuses on the understanding of the various forms of cardiac tumors, genetic variants involved and their influence, genetic testing, and different diagnostic approaches in cardiac tumors.

Epigenetic responses of hare barley (Hordeum murinum subsp. leporinum) to climate change: an experimental, trait-based approach

The impact of reduced rainfall and increased temperatures forecasted by climate change models on plant communities will depend on the capacity of plant species to acclimate and adapt to new environmental conditions. The acclimation process is mainly driven by epigenetic regulation, including structural and chemical modifications on the genome that do not affect the nucleotide sequence. In plants, one of the best-known epigenetic mechanisms is cytosine-methylation. We evaluated the impact of 30% reduced rainfall (hereafter "drought" treatment; D), 3 °C increased air temperature ("warming"; W), and the combination of D and W (WD) on the phenotypic and epigenetic variability of Hordeum murinum subsp. leporinum L., a grass species of high relevance in Mediterranean agroforestry systems. A full factorial experiment was set up in a savannah-like ecosystem located in southwestern Spain. H. murinum exhibited a large phenotypic plasticity in response to climatic conditions. Plants subjected to warmer conditions (i.e., W and WD treatments) flowered earlier, and those subjected to combined stress (WD) showed a higher investment in leaf area per unit of leaf mass (i.e., higher SLA) and produced heavier seeds. Our results also indicated that both the level and patterns of methylation varied substantially with the climatic treatments, with the combination of D and W inducing a clearly different epigenetic response compared to that promoted by D and W separately. The main conclusion achieved in this work suggests a potential role of epigenetic regulation of gene expression for the maintenance of homoeostasis and functional stability under future climate change scenarios.

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.

The history of transesophageal echocardiography: the role of inspiration, innovation, and applications

Transesophageal echocardiography (TEE), which is commonly used for monitoring and diagnostic imaging during cardiovascular surgery, was originally developed by a strong desire to know what was taking place in the heart in the dark ages of cardiac surgery. The author was fortunate to be present in the midst of the development of TEE and have an opportunity to take a close look at the history of this innovation. Furthermore, the author believes that the history of TEE contains important lessons and tips for solving the problems we presently face in clinical practice. This article describes the history of TEE based on the reports in the early stage of development and discuss how inspiration and innovation was generated by a strong wish and passion to overcome problems. The development of TEE was based on the collaboration of colleagues in different fields, and an intense desire to convert ideas into reality.

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.

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.

A case of cardioembolic stroke due to intracardiac papillary fibroelastoma evaluated by using transesophageal echocardiography

A 62-year-old woman had a prior ischemic stroke in the right temporal lobe with dysarthria and dysesthesia of the left hand. Embolic stroke of undetermined source (ESUS) was diagnosed and warfarin was administered. However, transient ischemic attack recurred upon admission to our hospital. Paroxysmal atrial fibrillation and cerebral arterial stenotic lesions were absent. Transesophageal echocardiography revealed a mobile hyperechoic structure on the aortic valve indicating papillary fibroelastoma. She was diagnosed with a brain embolism due to the intracardiac tumor which was surgically excised and pathologically confirmed as papillary fibroelastoma. This type of tumor is relatively rare but it is important as an embolic source especially in ESUS. Transesophageal echocardiography was indispensable for detecting the embolic source in this patient with ESUS.

Fibroelastoma as a Culprit of Syncope

We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed.

Left atrium papillary fibroelastomas: a cause of cerebral emboli

Papillary fibroelastomas are cardiac benign tumours. Among the benign cardiac tumor, papillary fibroelastomas are reported second after myxomas. Most often diagnosed incidentally, papillary fibroelastomas may embolize to cerebral circulation. Valvular locations are predominant; location in left atrium is rare. In this paper, we present a case of papillary fibroelastoma located in left atrium with symptoms of cerebral embolization. Transoesophageal echocardiography diagnosed a mobile mass. The patient was treated with surgical resection without further embolic complication.

Tricuspid valve papillary fibroelastoma: an unusual case of dizzy spells

An 81-year-old woman with recurrent episodes of dizzy spells was found to have a mass in the right atrium on transthoracic echocardiography. The patient underwent successful surgery to excise the mass, which was arising from the anterior leaflet of the tricuspid valve. Histology showed a papillary fibroelastoma. Although management is still controversial when such tumours are found incidentally in asymptomatic patients, surgery may be considered, especially if the tumour is large, due to the high risk of embolism.

Surgical treatment for primary mitral valve tumor: a 25-year single-center experience

OBJECTIVE

Primary mitral valve (MV) tumor is a rare lesion, and to date, there have been few larger surgical series of MV tumors. We retrospectively analyzed 11 cases of primary MV tumors regarding clinical and pathological features, surgical procedure and long-term outcomes.

METHODS

From November 1983 to December 2008, we operated on 11 patients (age 36.3 ± 17.7 years, weight 55.4 ± 11.2 kg) with primary MV tumors. Symptoms were cardiac in 8 cases (72.7%) and neurologic in 3 (26.3%). Surgical procedures included en bloc excision and MV repair in 8 cases and tumor resection and MV replacement in 3. No radiotherapy or chemotherapy was given to patients with malignant tumors.

RESULTS

Pathological diagnosis was papillary fibroelastoma in 3 cases, myxoma in 3, lymphangioma in 1, lipoma in 1, hemangioma in 1 and sarcoma in 2. No early deaths or complications occurred. Late death occurred in 2 patients with sarcoma 1 year postoperatively. At the latest follow-up, with a maximum of 25 years (mean 10.6 ± 8.8), the 9 survivors were in New York Heart Association functional class I with normal MV function and no echocardiographic evidence of local recurrence.

CONCLUSIONS

The majority of primary MV tumors are benign. They can cause cardiac or neurologic symptoms and should be excised as soon as a diagnosis is made. For benign tumors, valve-sparing resection and valve repair are often possible with excellent long-term outcomes. The prognosis of malignant MV tumors is poor.

Fibroelastoma of the mitral valve as a cause of embolic cerebral infarction

The authors report a case of cerebral infarction in a young woman with no obvious risk factors for stroke. The use of effective cardiac imaging enabled a diagnosis of mitral valve papillary fibroelastoma to be made and aided effective surgical management.

Cardiac papillary fibroelastoma as a cause of embolic stroke: ultrasound and histopathological characteristics

Although a cardiac papillary fibroelastoma is a benign cardiac tumor, it can cause severe embolic complications. A 51-year-old man presented with an ischemic stroke in the right middle cerebral artery territory. Transesophageal echocardiography revealed a small mobile tumor on the mitral valve as the only detectable source of emboli to the brain. On histology, the tumor was diagnosed as a papillary fibroelastoma. In this paper, the detailed characteristics of the tumor on ultrasound and histopathology are documented. In patients with cryptogenic stroke, transesophageal echocardiography should be done to rule out such an unusual emboligenic heart disease.

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

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

Cardioembolic stroke due to papillary fibroelastoma

Papillary fibroelastoma (PFE) is a rare primary benign cardiac tumor with significant embolic potential. Diagnosis and requisite surgical treatment may be neglected unless transesophageal echocardiography (TEE) is performed. A 72-year-old man with hypertension and diabetes had a right middle cerebral artery stroke of unclear cause after standard work-up. Subsequent TEE indicated an aortic valve PFE. The TEE may be the only diagnostic modality to identify embolic lesions such as PFE and must be strongly considered in cryptogenic large vessel stroke.

Cardiac papillary fibroelastoma of the mitral chorda

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

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

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

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

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

Papillary fibroelastoma, a rare but potentially treatable cause of embolic stroke: report of three cases

Papillary fibroelastomas are rare benign tumours that are seldom diagnosed during life. We report three cases of this tumour; two patients had recurrent embolic events, and one was diagnosed incidentally. Although rare, these tumours are a potentially treatable cause of cardiac emboli. Prompt identification allows excision, which generally is curative.

Aortic valve lipomatous hamartoma in a young woman

We present a rare case of lipomatous hamartoma of the aortic valve. A 17-year-old woman was admitted with cardiac murmur. Echocardiography demonstrated severe aortic regurgitation and a highly echoic mass on the right cusp of the aortic valve. Surgery was performed with a differential diagnosis of chronic infective endocarditis or aortic valve tumor. At operation, a yellowish bead-shaped tumor was detected on the right cusp of the aortic valve, and aortic valve replacement was performed. Histopathological examination confirmed a lipomatous hamartoma. To the best of our knowledge, this is the first reported case of a lipomatous hamartoma located on the aortic valve.

Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases

BACKGROUND

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

DATA COLLECTIONS

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

RESULTS AND CONCLUSIONS

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

Aortic valve fibroelastomas as an incidental intraoperative transesophageal echocardiographic finding

IMPLICATIONS

We report incidental findings of aortic valve fibroelastomas during routine intraoperative transesophageal echocardiography examination in cardiac surgery. Preoperative echocardiography failed to identify this potentially devastating pathology. The echocardiographic features of this lesion are reviewed, and the importance of diligence and complete examination are emphasized.

Papillary fibroelastoma of the aortic valve

We hereby report the case of a patient with a papillary fibroelastoma involving the right coronary cusp of the aortic valve that was diagnosed with the use of transesophageal echocardiography after workup for recurrent transient ischemic attacks.

Infected papillary fibroelastoma attached to the atrial septum

A 61-year-old woman had intermittent fever of 2 months' duration following a dental extraction. On admission, her body temperature was 39.2 degrees C. A mid-systolic murmur was heard at the apex on ausculation. A 2-dimensional echocardiogram revealed a mobile, heavy stick-like mass with vegetation (5.0 x 1.5 cm) attached to the left atrial septum. Multiple blood cultures grew Streptococcus constellatus. On diagnosis of an infected left atrial myxoma, antibiotics were administered daily and 4 weeks later, the left atrial tumor was resected. The tumor was 5.3cm long, 1.5cm in diameter at the inter-atrial wall and had vegetation on the free edge. On microscopic examination, colonies of Gram-positive cocci were found in the thrombus, on the papillary fibroelastoma. After treatment with antibiotics for a further 4 weeks, the patient was discharged. This is the first report of infected papillary fibroelastoma.

Transesophageal echocardiographic (TEE) evaluation of intracardiac and pericardial masses

Transesophageal echocardiography has assisted the detection of intracardiac masses and, in certain cases, aided our ability to define the specific type of mass. This technique, when coupled with three-dimensional imaging, may help to define infiltration of the wall. TEE aids in the intraoperative management of cardiac tumors.

Papillary fibroelastoma in association with thrombosis on a mechanical valve

A patient with a thrombosed mechanical valve underwent valve re-replacement during which a tumor of the left ventricular outflow tract with the typical macroscopic and microscopic characteristics of a papillary fibroelastoma was successfully removed surgically. The 60-year-old woman had undergone isolated mitral valve replacement with a St Jude Medical 29-mm valve for mitral regurgitation 15 years ago. The present admission was for investigation of dyspnea on exertion. Two-dimensional transthoracic echocardiography demonstrated a posteroseptal, pedunculated mass, measuring 1.3x1.0 cm, in the outflow tract of the left ventricle, mild mitral regurgitation and slight aortic stenosis.

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

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

CASE REPORTS

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

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.

Ischemic stroke associated with activated protein C resistance and aortic valvular papillary fibroelastoma

We report an unusual case of a pontine ischemic stroke associated with activated protein C resistance as well as an embolic source in the form of a cardiac valvular lesion. A 31-year-old man had a sudden onset of right hemiparesis and a severe dysarthria. Cranial magnetic resonance imaging (MRI) showed a nonhemorrhagic pontine lesion with essentially negative craniocervical MR angiography. His transesophageal echocardiogram showed a papillary fibroelastoma on the aortic valve. His laboratory studies showed significant activated protein C resistance at 1.7 (normal, >2.1). Other laboratory parameters, including sedimentation rate, were unremarkable. This case suggests that activated protein C resistance may serve as a cofactor in some cases of ischemic stroke, particularly stroke associated with emboligenic cardiac lesions.

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

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

Hamartoma of the mitral valve with blood cysts: a rare tumor detected by echocardiography

A 16-year-old boy was submitted to a cardiac examination after an episode of faintness. A transthoracic echocardiogram was performed, which revealed a very mobile multicystic tumor attached to the mitral valve. A small solid mass adherent to the cysts was better defined by transesophageal echocardiography. The patient was submitted to cardiac surgery consisting of tumor resection and a mitral prosthesis implant. The surgery was successful. The tumor consisted of three bright red tense cysts with hematic content, each 1 to 2 cm in diameter. The cysts were coalescent and adherent to a solid mass attached to the posterior papillary muscle head. Histopathologic examination revealed a hamartoma with a cystic part composed of the proliferation of myofibroblast cells in a stroma with vessels, collagen, and elastin fibers. Valvular hamartoma with blood cysts is a very rare cardiac tumor both for its histopathology and its localization.

[Papillary fibroelastoma. A rare etiology of strokes in young patients]

BACKGROUND

The papillary fibroelastomas are cardiac lesions, which typically occur on the cardiac valves, but rarely on the endocardium. The incidence of these benign primitive tumors varies from 0.002 to 0.33% and increases with advancing age.

METHODS

We report two cases of stroke, one in a 31-year-old man and the other in a 48-year-old woman, both admitted to the same stroke center.

RESULTS

The diagnostic studies were normal in these two patients, except for the echocardiography. The first showed an echogenic mass on the mitral valve on transthoracic echocardiography (TTE), confirmed by the transesophageal echocardiography (TEE). The second demonstrated a mass on the sigmoid aortic valve on TEE, but the TTE was normal. For these two patients, a surgical excision was carried out and pathologic examination concluded to a papillary fibroelastoma. After surgery, no recurrence was observed.

CONCLUSIONS

The papillary fibroelastomas are usually asymptomatic and easily detected by TEE. However, it can be revealed by stroke, myocardial infarction and lower limbs ischemia. These cardiac tumors should be surgically removed, since their complete excision remains the only means of avoiding a recurrence of embolism.

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.

Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mitral valve strands and the risk of ischemic stroke in elderly patients. The French Study of Aortic Plaques in Stroke (FAPS) Investigators

BACKGROUND AND PURPOSE

Strands are thin and filamentous attachments on the cardiac valves shown by transesophageal echocardiography. Their nature and their potential for embolization are largely unknown. The objective was to estimate the risk of brain infarction in patients with mitral valve strands.

METHODS

Using transesophageal echocardiography, we compared the frequency of strands on native mitral valves in 284 consecutive patients admitted with brain infarction and 276 control patients, all older than 60 years. In a second part, case subjects were followed up over a 2- to 4-year period, and the risk of recurrence of brain infarction was estimated in patients with and without strands.

RESULTS

In the case-control study, mitral valve strands were found in 22.5% of the case patients and in 12.1% of the control subjects. In case subjects, mitral valve strands were more frequent in those with mitral valve dystrophy (52.4% versus 37.4%; P = .03). Strands were not associated with mitral valve prolapse, annular calcifications, or left atrial spontaneous echocardiographic contrast. After adjustment for age, sex, and mitral valve dystrophy, the odds ratio for ischemic stroke among patients with mitral strands was 2.2 (95% confidence interval, 1.4 to 3.6; P = .005). The frequency of strands was not different in patients with a known cause of brain infarction (24.4%) from that in patients with no other apparent cause (20.9%). During 646 per 100 person-years of follow-up, the incidence of recurrent brain infarction was 6.0 person-years in patients with strands and 4.2 in those without. In the Cox analysis, including potential confounders and poststroke treatment, mitral valve strands did not appear as independent predictors of recurrent brain infarction (relative risk, 1.3; 95% confidence interval, 0.5 to 3.0; P = .54).

CONCLUSIONS

The present study shows an independent association between mitral valve strands and the risk of brain infarction. However, the lack of an increased relative risk of recurrence raises doubts about the potential causal relation with brain infarction in patients aged 60 years or older.

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.

Visualization of ventricular fibroelastoma with a video-assisted thoracoscope

Left ventricular papillary fibroelastomas are associated with a high risk of cerebral embolization. Two-dimensional echocardiography and intraoperative transesophageal echocardiography are helpful in diagnosing tumors, planning a surgical approach, and achieving adequate excision. A video-assisted thoracoscope via the left atrium was used to visualize a left ventricular papillary fibroelastoma. Thoracoscopic visualization facilitated excision of a mass within the chordae tendineae between the anterolateral papillary muscle and the left ventricular wall. Video-assisted thoracoscopy greatly facilitates exposure/excision of deeper intracavitary left ventricular masses.

Papillary fibroelastoma of the mitral valve in a 3-year-old child: case report

A 3.5-year-old boy with stroke secondary to embolization of a primary cardiac tumor is presented. The diagnosis was made by two-dimensional echocardiography and confirmed intraoperatively. A papillary fibroelastoma was identified histologically. It is a rare condition and a diagnostic challenge, as patients are asymptomatic before embolization. In view of the severe consequences, prompt surgery is recommended.

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

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