Prognostic and Bioepidemiologic Implications of Papillary Fibroelastomas. J Am Coll Cardiol. 2015;65:2420-2429. [PMID: 26046736 DOI: 10.1016/j.jacc.2015.03.569]

Cardiac papillary fibroelastomas: Unveiling a rare right atrial presentation with surgical insights-A case report and review of the literature

Cardiac papillary fibroelastomas (CPF) are rare, benign tumors with thromboembolic potential. We present a 40-year-old male with a right atrial CPF, referred with acute chest pain. Advanced imaging and surgical excision with tricuspid valve repair were crucial, emphasizing the need for early detection and intervention in symptomatic and asymptomatic cases.

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

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

Radiologic-Pathologic Correlation of Cardiac Tumors: Updated 2021 WHO Tumor Classification

Cardiac tumors, although rare, carry high morbidity and mortality rates. They are commonly first identified either at echocardiography or incidentally at thoracoabdominal CT performed for noncardiac indications. Multimodality imaging often helps to determine the cause of these masses. Cardiac tumors comprise a distinct category in the World Health Organization (WHO) classification of tumors. The updated 2021 WHO classification of tumors of the heart incorporates new entities and reclassifies others. In the new classification system, papillary fibroelastoma is recognized as the most common primary cardiac neoplasm. Pseudotumors including thrombi and anatomic variants (eg, crista terminalis, accessory papillary muscles, or coumadin ridge) are the most common intracardiac masses identified at imaging. Cardiac metastases are substantially more common than primary cardiac tumors. Although echocardiography is usually the first examination, cardiac MRI is the modality of choice for the identification and characterization of cardiac masses. Cardiac CT serves as an alternative in patients who cannot tolerate MRI. PET performed with CT or MRI enables metabolic characterization of malignant cardiac masses. Imaging individualized to a particular tumor type and location is crucial for treatment planning. Tumor terminology changes as our understanding of tumor biology and behavior evolves. Familiarity with the updated classification system is important as a guide to radiologic investigation and medical or surgical management. ©RSNA, 2024 Supplemental material is available for this article.

Genetics of Cardiac Tumours: A Narrative Review

Cardiac tumours can occur in association with genetic syndromes. Rhabdomyomas have been reported in association with tuberous sclerosis, myxomas with Carney's complex, cardiac fibromas with Gorlin syndrome, and paragangliomas with multiple endocrine neoplasm syndrome. The presentation and prognosis of cardiac tumours associated with genetic syndromes differ compared with sporadic cases. Knowledge about the associated syndromes' genetic features and extracardiac manifestations is essential for the diagnosis, prognosis, and management of cardiac neoplasms. Moreover, identifying genetic mutations in benign and malignant cardiac tumours is needed to personalise management and improve treatment outcomes. Thus, this review discusses the genetic abnormalities associated with cardiac tumours, the current genetic screening recommendations, and the effect of those genetic mutations on the outcomes.

Rheumatic heart disease of the mitral valve alongside the papillary fibroelastoma of the aortic valve: A case report

Key Clinical Message

Besides thromboses, it's crucial to also consider the rare possibility of tumors like papillary fibroelastomas when evaluating worsening cardiopulmonary symptoms in patients with severe rheumatic mitral stenosis and atrial fibrillation.

Abstract

Cardiac papillary fibroelastoma is a rare and benign endocardial tumor typically found on the aortic valve. The simultaneous occurrence of rheumatic heart disease affecting the mitral valve and papillary fibroelastoma on the aortic valve is infrequent, with limited documented instances. This unique case can enhance our understanding of the clinical presentation, diagnostic approaches, management options, and implications for patient outcomes in these two conditions. We present the case of a 47-year-old woman who was admitted to the hospital due to worsening dyspnea and fatigue, during which time she discovered an aortic valve papillary fibroelastoma. Further investigations revealed two thrombi in her left atrium and left atrial appendage, along with significant rheumatic mitral valve stenosis. The patient underwent thrombectomy, mitral valve replacement, and valve-sparing aortic valve tumor resection. Following surgery, the patient's recovery was unremarkable. This case report emphasizes the need for a comprehensive evaluation in patients with rheumatic mitral stenosis, considering all possible etiologies. While thrombi are typical in mitral stenosis and atrial fibrillation, the rare presence of tumors like papillary fibroelastomas should be recognized, underscoring the importance of further assessment when suspicion arises. Importantly, individuals with asymptomatic cardiac papillary fibroelastomas should undergo surgical treatment to minimize the potential risk of tumoral embolization.

Cardiac Computed Tomography of Native Cardiac Valves

Valvular heart disease (VHD) is a significant clinical problem associated with high morbidity and mortality. Although not being the primary imaging modality in VHD, cardiac computed tomography (CCT) provides relevant information about its morphology, function, severity grading, and adverse cardiac remodeling assessment. Aortic valve calcification quantification is necessary for grading severity in cases of low-flow/low-gradient aortic stenosis. Moreover, CCT details significant information necessary for adequate percutaneous treatment planning. CCT may help to detail the etiology of VHD as well as to depict other less frequent causes of valvular disease, such as infective endocarditis, valvular neoplasms, or other cardiac pseudomasses.

A Case Series of Minimally Invasive Robotic-Assisted Resection of Cardiac Papillary Fibroelastoma: The Mayo Clinic Experience

Papillary fibroelastomas (PFEs) are small, slowly growing benign cardiac tumors with clinically significant risk of embolization. Surgical excision is the definitive treatment of symptomatic PFE and is conventionally performed through a median sternotomy. In this study, we report a series of 12 patients, who underwent robotic-assisted PFE removal at the Mayo Clinic. PFE involved the mitral valve, left atrium, and tricuspid valve. No major complications occurred after the procedure, and most patients were discharged 4 days after the surgery. On follow-up, 1 patient demonstrated pericarditis.

Coexistence Case of Papillary Fibroelastoma and Lambl's Excrescence of the Left Heart, Which Is Occasionally Associated with Significant Stroke

Papillary fibroelastoma (PFE) is a benign tumor that arises mostly from left-sided valves. PFE can cause stroke, and surgical resection may be needed. Lambl's excrescence (LE) is a filiform valvular lesion and is considered a possible cause of stroke. A 79-year-old man with light-headedness and left-sided hemiparesis was diagnosed with stroke. Transesophageal echocardiography (TEE) revealed a round-shaped mobile mass in the left ventricular outflow tract (LVOT), which was considered the cause of the stroke. Surgical resection was performed transaortically, and during surgery, a mass was incidentally detected on the noncoronary cusp (NCC), which was also resected followed by aortic valve replacement. Pathology confirmed that the mass in the LVOT was a PFE and that the filiform mass on the NCC was LE. We herein report a rare case of PFE in the LVOT and coexisting LE on the NCC. A careful examination via TEE helps to identify other possible causes of stroke hidden behind the obvious cause.

Clinical presentation, diagnostic evaluation, and management of undifferentiated/unclassified cardiac sarcoma: A case report and literature review

This case report details a challenging instance of undifferentiated/unclassified cardiac sarcoma in a 28-year-old female, presenting with diverse symptoms like muscle weakness, shortness of breath, and hemoptysis. Diagnostic hurdles led to an initial misdiagnosis of granulomatosis with polyangiitis before discovering a sizable left atrial mass, ultimately diagnosed as high-grade undifferentiated/unclassified sarcoma. Despite initial surgical intervention, the patient's condition worsened, underscoring the complexities in managing such cases involving cardiac sarcomas. This case emphasizes the diagnostic complexities associated with primary cardiac sarcomas, particularly the challenges in achieving accurate diagnoses and formulating effective treatment strategies.

Operative management of cardiac papillary fibroelastomas

OBJECTIVE

Papillary fibroelastomas are associated with an increased risk of embolic strokes. Excision of papillary fibroelastomas may be the primary indication for surgery (primary) or performed during other cardiac operations (secondary). The present study summarizes our experience with primary and secondary fibroelastoma surgery.

METHODS

We analyzed the medical records of patients who underwent surgical excision of papillary fibroelastoma between January 1998 and February 2020. Patient characteristics, indications for operation, tumor size and location, and operative and long-term outcomes were evaluated.

RESULTS

Among the 294 patients (median age: 66 years, 62% female), papillary fibroelastoma was the primary indication for surgery in 136 patients (46%), and 51% of patients had a history of stroke or transient ischemic attack. When papillary fibroelastoma was a secondary indication for surgery (158 patients, 54%), the lesion was identified preoperatively in 39%. Papillary fibroelastomas were located most commonly on the aortic valve and least commonly in the right side of the heart. For valvular papillary fibroelastoma resected from a normal valve, valve shave was sufficient in 96% (196/205). Operative mortality was low in both groups (primary, 0% vs secondary, 2.5%, P = .13), and early neurologic events occurred in 1.3%. Recurrence rate was 15.8% at 10 years. The estimated survival for patients with primary papillary fibroelastoma at 10 years was 78.4%, whereas for secondary papillary fibroelastoma removal it was 53.6% (log rank, P = .003).

CONCLUSIONS

Resection of papillary fibroelastomas can be performed safely, with preservation of the native valve, and with low rates of neurologic events. Operative and long-term outcomes after fibroelastoma resection are excellent.

Fibroelastoma, an Incidentaloma Disease? - Image Cases of Fibroelastomas as Incidental Findings in Four Patients, Four Different Valves

Fibroelastomas are the second most common benign cardiac tumor1. They are small avascular structures with a mean size of 9mm, ranging up to 70mm, usually attached to the heart valves' surface (aortic and mitral are the most affected, followed by tricuspid and pulmonary valves). Their etiology is unclear, but the hypothesis of coalescence of microthrombus at the coaptation margins of valves is the most widely accepted theory. On echocardiography, they are pedicled, mobile, with a filamentous surface, and usually have a speckled appearance with echolucencies and a stippled pattern near the edges. Clinically, they may be associated with embolic phenomena; however, in most cases, the diagnosis is incidental. We present a series of four clinical cases with an incidental diagnosis of fibroelastomas across the four cardiac valves as assessed by transthoracic echocardiography (Video 1; Figure 1). Video 1 From left to right and top to bottom: fibroelastomas of the anterior leaflet of the tricuspid valve, anterior leaflet of the mitral valve, left cusp of the pulmonary valve and left cuspid of the aortic valve, each corresponding to a different patient. Link: http://abccardiol.org/supplementary-material/2024/12102/2023-0222_IM_video01.mp4 Figure 1 From left to right and top to bottom: fibroelastomas of the anterior leaflet of the tricuspid valve, anterior leaflet of the mitral valve, left cusp of the pulmonary valve and left cuspid of the aortic valve, each corresponding to a different patient.

Case Report: A myxoma with a far reach

A 73-year-old woman presented to the emergency department with a syncopal episode and a history of dizzy spells. A transthoracic echocardiogram demonstrated a large left atrial mass extending into the right upper pulmonary veins. Subsequently, cardiac magnetic resonance imaging and coronary computed tomography angiography with three-dimensional reconstruction and printing of the heart and mass were performed, which demonstrated a high index of suspicion for an atypical left atrial myxoma. The mass was excised robotically, and the pathology report confirmed a diagnosis of myxoma.

Case series: cardiac sarcoma

Background

Cardiac masses encompass a wide differential including primary and secondary malignancies and can present with a variety of symptoms, many of which are non-specific. Early identification and classification are important, particularly for cardiac malignancies such as sarcomas as these are aggressive tumours with exceptionally poor prognoses when metastases are present at diagnosis.

Case summary

We report two cases of patients who presented with dyspnoea and were diagnosed with cardiac sarcomas; the former a primary sarcoma (undifferentiated pleomorphic subtype) and the latter a secondary sarcoma (round cell myxoid liposarcoma) that serve as comparisons for presentation and management of different types of this disease. Computed Tomography (CT) and echocardiography imaging findings are demonstrated showing the typical location and morphology of each subtype.

Discussion

Cardiac sarcomas are the most common primary cardiac malignancy, of which undifferentiated pleomorphic sarcoma is a common subtype. Undifferentiated pleomorphic sarcomas are aggressive, have a tendency to arise in the left atrium, and can appear similar to benign cardiac masses. Round cell myxoid liposarcomas by contrast are rare causes of secondary cardiac malignancies, metastasizing to the heart from soft tissues. Both diagnoses carry poor prognoses and although rare, are important to recognize as timely intervention with surgery, radiotherapy, and consideration of chemotherapy is key to maximizing survival.

Concomitant minimally invasive surgery for tricuspid valve papillary fibroelastoma and right lung cancer in an elderly patient: a case report and review of the literature

BACKGROUND

It is very common for patients with newly diagnosed lung masses to have heart disease. However, papillary fibroelastomas (PFEs) of the tricuspid valve (TV) combined with lung cancer are rarely reported. It is thus unclear whether a two-stage surgery or concomitant surgery is optimal.

CASE PRESENTATION

We report the case of a 73-year-old Chinese male who was diagnosed with PFEs on the TV by transthoracic echocardiography (TTE) examination while being evaluated to undergo video-assisted thoracic surgery (VATS) for a right lower lung nodule. We resected both the PFEs and the lung nodule via right minithoracotomy. The surgery was uneventful, and histopathology reports confirmed PFEs of the TV and moderately to poorly differentiated squamous cell carcinoma. The patient recovered uneventfully, and there was no sign of tumor recurrence during 15 months of follow-up.

CONCLUSIONS

We suggest that after careful evaluation, concomitant minimally invasive radical resection of primary lung cancer after cardiac PFE removal is an acceptable and safe treatment strategy and should be performed as soon as possible.

Cardiac papillary fibroelastoma: a rare cause of ST-segment elevation myocardial infarction: a case report

Introduction and importance

Primary tumors of the heart are extremely rare occurrences. Among them, cardiac papillary fibroelastoma (CPF) is the second most common type. Although these tumors are usually benign, they can pose a risk of embolization, which may lead to severe complications like sudden death or embolization affecting the neurological, systemic, or coronary vasculature. Such complications can be life-threatening.

Case presentation

In this report, the authors present the case of a 68-year-old woman who experienced ST-segment elevation myocardial infarction due to embolization from a large papillary fibroelastoma. To address the issue, the authors performed a minimally invasive surgical removal and resection of the aortic valve, followed by a histological examination to confirm the diagnosis.

Clinical discussion

This case report discusses a rare occurrence of myocardial infarction caused by tumor embolization from a CPF. The patient presented with complete blockage of a coronary artery in the absence of atherosclerotic disease. Through a comprehensive workup, including transesophageal echocardiography, the CPF was identified as the source of embolization. Surgical resection of CPFs is curative, and recurrence has not been documented. Clinicians should consider CPFs in cases of coronary artery occlusion without atherosclerotic disease and employ transesophageal echocardiography for diagnosis. Prompt surgical intervention leads to an excellent prognosis and prevents recurrent embolization.

Conclusion

This report emphasizes the importance of recognizing the potential complications associated with papillary fibroelastoma-induced embolization to the coronary arteries and highlights the need to mitigate the risk of such complications occurring.

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

BACKGROUND AND AIM

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

MATERIALS AND METHODS

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

CONCLUSIONS

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

Clinical presentation and neurovascular manifestations of cardiac myxomas and papillary fibroelastomas: a retrospective single-institution cohort study

Background

Primary cardiac tumors are often benign and commonly present as cardiac myxomas (CMs) or papillary fibroelastomas (CPFEs). There is a paucity of prognostic indicators for tumor burden or potential for embolic cerebrovascular events (CVEs). This study was performed to address these gaps.

Methods

Medical records at the University of Florida Health Shands Hospital between 1996 and 2021 were screened to identify patients with CMs or CPFEs. Clinical features, echocardiographic reports, and CVE outcomes were quantitatively assessed.

Results

A total of 55 patients were included in the study: 28 CM (50.9%) and 27 CPFE (49.1%) patients. Baseline patient characteristics were similar among patients. The neutrophil-lymphocyte ratio was correlated (p < 0.005 in all cases) to three metrics of tumor size in both CM (r = 64-67%) and CPFE (r = 56-59%). CVEs were the presenting symptom in 30 (54.5%) patients. CVE recurrence was high; the 5-year CVE recurrence rate in patients with tumor resection was 24.0% compared to 60.0% without resection. No baseline patient characteristics or tumor features were associated with an initial presentation of CVEs compared to any other indication. Univariate analysis indicated that prolonged duration to surgical resection, left atrial enlargement, male sex, and a neutrophil-lymphocyte ratio >3.0 at the follow-up were significantly associated with 5-year CVE recurrence. Left atrial enlargement and a neutrophil-lymphocyte ratio >3.0 at the follow-up remained significantly associated with 5-year CVE recurrence in multivariate analysis.

Conclusion

The neutrophil-lymphocyte ratio may prognosticate tumor size and recurrence of neurologic events. An increased risk of CVE within 5 years of mass resection is almost exclusive to patients initially presenting with CVEs.

Timing of Intervention for Left Ventricular Mass in the Setting of Acute Obstructive Coronary Artery Disease

•Comorbid need for antiplatelet therapy complicates intracardiac mass management. •Noninvasive mass diagnosis is invaluable for patients at high operative risk. •Guidelines for timing of intervention on masses are currently not well defined.

[Thromboembolic diseases from a cardiological point of view]

Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk.

Misdiagnosis of a Cardiac Angiosarcoma During the COVID-19 Pandemic

The final months of 2019 saw the emergence of a new pandemic termed "COVID-19". Since then, this infection and its complications have been the priority of healthcare providers, with many symptoms attributed to its early and late presentations. Thus far, other diseases, even fatal situations, have been overlooked or misdiagnosed due to the attribution of patient symptoms to the presence of COVID-19 infection. We herein present a case of cardiac angiosarcoma in a young boy who had previously become infected with COVID-19 about two months earlier. Given the history of infection, the initial approach was post-COVID-19 myopericarditis management. However, the patient's condition worsened, necessitating reevaluation via multimodalities with higher precision. Ultimately, the patient was diagnosed with a cardiac tumor. This article seeks to underscore the significance of taking heed of other diseases and fatal conditions during the COVID-19 pandemic with an emphasis on avoiding misdiagnosing other diseases.

Cardiac Masses Discovered by Echocardiogram; What to Do Next?

Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.

Diagnosis and Management of Cardioembolic Stroke

OBJECTIVE

Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke.

LATEST DEVELOPMENTS

Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy.

ESSENTIAL POINTS

A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.

Papillary fibroelastoma causing severe aortic stenosis

Herein, we present a rare case of papillary fibroelastoma of the aortic valve, which caused severe aortic stenosis. The papillary fibroelastoma developed on the left ventricular side of the non-coronary cusp, immobilizing the cusp motion and obstructing the left ventricular outflow tract, resulting in severe aortic stenosis that brought on acute heart failure. The patient underwent an urgent surgical treatment, which resulted in a successful outcome. To the best of our knowledge, this is the first case of papillary fibroelastoma in which aortic stenosis was so severe as to cause congestive heart failure.

Learning objective

Papillary fibroelastoma (PFE) is the most commonly observed primary cardiac tumor in adults that commonly involves left heart chambers. While PFEs often cause embolisms, they rarely cause valvular dysfunction. In a case presented herein, a PFE developed on the left ventricular side of the non-coronary cusp, immobilizing the cusp motion and obstructing the left ventricular outflow tract, resulting in severe aortic stenosis that brought on acute heart failure.

Pulmonary Fibroelastoma: A Rare Cardiac Mass Presenting With Dyspnea

•

PFEs are rare primary cardiac tumors.

•

Their presentation is often associated with embolic sequalae.

•

CMR has proven to be an invaluable tool in the diagnosis of cardiac masses.

Multimodality Imaging of Benign Primary Cardiac Tumor

Primary cardiac tumors (PCTs) are rare, with benign PCTs being relatively common in approximately 75% of all PCTs. Benign PCTs are usually asymptomatic, and they are found incidentally by imaging. Even if patients present with symptoms, they are usually nonspecific. Before the application of imaging modalities to the heart, our understanding of these tumors is limited to case reports and autopsy studies. The advent and improvement of various imaging technologies have enabled the non-invasive evaluation of benign PCTs. Although echocardiography is the most commonly used imaging examination, it is not the best method to describe the histological characteristics of tumors. At present, cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) are often used to assess benign PCTs providing detailed information on anatomical and tissue features. In fact, each imaging modality has its own advantages and disadvantages, multimodality imaging uses two or more imaging types to provide valuable complementary information. With the widespread use of multimodality imaging, these techniques play an indispensable role in the management of patients with benign PCTs by providing useful diagnostic and prognostic information to guide treatment. This article reviews the multimodality imaging characterizations of common benign PCTs.

Papillary Fibroelastoma Incidentally Found on Left Atrial Wall During Minimally Invasive Aortic Valve Replacement

A 60-year-old man was about to undergo minimally invasive aortic valve replacement when transesophageal echocardiography revealed an intracardiac mass on the left atrial free wall. Multimodal images from 5 months earlier had shown no mass. We converted the procedure to open surgery. The excised mass resembled a cardiac myxoma but was determined to be a papillary fibroelastoma. This case illustrates that papillary fibroelastomas can form and grow rapidly, warranting alertness for their unexpected discovery before and during cardiac surgical procedures.

Case report: Minimally invasive excision of multifocal cardiac papillary fibroelastomas involving right atrium and aortic valve

Background

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac tumors most commonly found on left-sided cardiac valves. Right atrial CPFs are extremely rare, accounting for only 2% of all CPFs. Median sternotomy is a typical approach for surgical excision of CPFs in most cases. Herein, we report an extremely rare case of multifocal CPFs involving the right atrium and aortic valve that were surgically excised via minimally invasive right anterolateral thoracotomy.

Case Summary

A 59-year-old Chinese man was admitted because of an incidental finding of a right atrial mass on transthoracic echocardiography during a routine check-up. The mass was initially diagnosed as a myxoma, and the patient was scheduled for minimally invasive excision via right anterolateral thoracotomy. An additional mass on the non-coronary cusp of the aortic valve was identified using intraoperative transesophageal echocardiography. The patient still underwent complete tumor excision via right anterolateral thoracotomy. Both neoplasms were pathologically diagnosed as CPFs.

Conclusions

This case highlights the need for a comprehensive cardiac evaluation of cardiac tumors because CPFs can manifest as multifocal lesions. Moreover, minimally invasive surgery is highly feasible as the CPF can be easily excised, and the valve can usually be preserved.

Rare case of papillary fibroelastoma resection with concomitant cox-maze IV procedure

Primary cardiac tumors represent 0.1% of all cardiac tumors, making them a rare pathologic phenomenon. The second most common cardiac tumors are papillary fibroelastomas, which also represent the most common valvular tumors. This report examines a rare case of a patient that underwent resection of papillary fibroelastoma with simultaneous Cox-Maze IV procedure for treatment of atrial fibrillation. This 67-year-old male patient was initially scheduled for transcatheter ablation for treatment of rate-controlled atrial fibrillation. During a pre-procedural trans-thoracic echocardiogram, it was discovered that the patient had a moderately sized pedunculated mass on the aortic valve, suspicious of papillary fibroelastoma. Despite the patient having no history of embolic events or aortic insufficiency from the papillary fibroelastoma, the transcatheter ablation procedure was canceled. He was referred to cardiothoracic surgery for further evaluation, and it was determined that this patient was a candidate for papillary fibroelastoma resection along with Cox-Maze IV procedure for atrial fibrillation.

Surgical treatment of papillary fibroelastoma of the pulmonary valve: a case report

Background

Cardiac papillary fibroelastoma (PFE) is a rare tumor, and especially rare when found on the pulmonary valve.

Case presentation

We report the case of a 70-year-old woman patient with a pulmonary valve PFE diagnosed incidentally during a follow-up of aortic regurgitation. Computed tomography and magnetic resonance imaging showed no suggestive signs of malignant tumors, and thrombus or myxoma was initially suspected. However, an initial transthoracic and transesophageal echocardiogram did not exclude the possibility of a malignant tumor attached to the wall of the pulmonary artery. Considering the embolization risk, we opted to perform tumorectomy, in which additional surgical procedures could then be conducted if intraoperative diagnosis showed a malignant tumor. Indeed, intraoperative findings showed the tumoral mass attached on the left semilunar cusp of the pulmonary valve, and intraoperative diagnosis of the tumor showed no malignancy. Planned tumorectomy was performed concomitantly with AVR. The pathologic examination of the removed tumor confirmed the diagnosis of PFE. Her postoperative course was uneventful without any sign of recurrence.

Conclusion

This case highlights the difficulty of accurate diagnostic imaging and provides valuable insight into a successful surgical treatment of pulmonary valve PFE without any complications.

Cardiac Imaging for Diagnosis and Management of Infective Endocarditis

Imaging is central to the care of patients with infective endocarditis. While transthoracic and transesophageal echocardiography are the principle imaging techniques, additional modalities including positron emission tomography and cardiac computed tomography, and to a lesser extent intracardiac echocardiography, play an increasing role. This review discusses the role of cardiac imaging in establishing the diagnosis of endocarditis, in predicting its embolic risk and in making decisions regarding the need for and timing of surgery.

Clinical Problem-Solving: 72-Year-Old Woman With Multifocal Strokes and an Intracardiac Mass

We present the case of a 72-year-old female with multifocal strokes found to have multiple, mobile intracardiac masses. We discuss the differential diagnosis and evaluation of intracardiac masses, and the challenges in management of the ultimately diagnosed etiology of stroke in this patient.

Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies

The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.

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.

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

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

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

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

Clinical and echocardiographic characteristics of patients with pathology proven right-sided papillary fibroelastomas

BACKGROUND

Papillary fibroelastoma (PFE) are one of the most common primary cardiac neoplasms. They are most commonly found on cardiac valves especially on the left side of the heart and have been associated with an increased risk of embolization. To date, no large studies looked at the clinical significance of right-sided PFE (R-PFE). Therefore, we sought to better characterize patients with R-PFE and its clinical sequelae.

METHODS

We retrospectively identified patients with pathology-proven PFEs at a single center between January 1995 and December 2018 (n = 279). Patients with R-PFE were analyzed. Medical records and echocardiograms were reviewed for clinical and PFE characteristics.

RESULTS

Twenty-nine patients with R-PFE (mean age 70 ± 11 years; 62% women) were included in the analysis. PFEs were located on the right atrial (RA) wall in 31%, tricuspid valve in 34%, right ventricular (RV) wall in 7%, RV outflow tract in 4%, and pulmonary valve in 10% of patients. The remaining patients (14%) had multifocal PFEs. Around 38% of patients had cancer diagnosed before PFE diagnosis, and 34% had associated congenital heart disease. Seventeen (59%) patients had angina or dyspnea at the time of the presentation, and 3 (10%) had embolic symptoms. One patient with PFE located on the RA with associated patent foramen ovale had a stroke at time of presentation. Two patients, one with PFE on the RA wall and another patient with PFE at the tricuspid valve, had pulmonary embolism at the time of presentation. Median maximal length for PFE varied by location, ranging from a media of 8 mm to 16 mm. Of the 12 patients with follow up echocardiogram 1 year after PFE removal; 3/12 (25%) had documented PFE recurrence.

CONCLUSION

R-PFE can be present in patients thromboembolic events when there is a right-to-left shunt. They can be a rare cause of pulmonary embolism, and at least in those that had follow-up echocardiograms, had a significant recurrence rate.

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.

A rare case of acute myocardial infarction related to mobile papillary fibroelastoma of the aortic valve

We present the case of a 75-year-old woman with typical myocardial infarction but a negative coronary angiogram. Echocardiography identified the rare cause of her chest pain: a mobile mass on the aortic valve that obstructed the coronary ostium. The histopathology revealed a papillary fibroelastoma (PFE), and her chest pain was relieved after surgical resection of the mass.

Society for Cardiovascular Magnetic Resonance 2020 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). Case of the week is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. Each case consists of the clinical presentation and a discussion of the condition and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2020 Case of the Week series of 11 cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.