Papillary fibroelastoma of the aortic valve presenting with myocardial infarction

Coronary Embolism: A Systematic Review

BACKGROUND

Coronary embolism is a rare and potentially fatal phenomenon that occurs primarily in patients with valvular heart disease and atrial fibrillation. There is a lack of consensus regarding the diagnosis, treatment, and management of coronary embolism, leaving management at the discretion of the treating physician. Through this review, we aim to establish a better understanding of coronary embolism, and to identify treatment options - invasive and non-invasive - that may be used to manage coronary embolism.

METHODS AND RESULTS

Our systematic review included 147 documented cases of coronary embolism from case reports and case series. The average age of our population was 54.2 ± 17.6 years. The most common causes of coronary embolism included infective endocarditis (22.4%), atrial fibrillation (17.0%), and prosthetic heart valve thrombosis (16.3%). Initial presentation was indistinguishable from an acute coronary syndrome (ACS) due to coronary atherosclerosis, and the diagnosis required a high level of suspicion and evaluation with angiography. Treatment strategies included, but were not limited to, thrombectomy, thrombolysis, balloon angioplasty and stent placement. Myocardial dysfunction on echocardiography was observed in over 80% of patients following coronary embolism. "Good outcomes" were reported in 68.7% of case reports and case series, with a mortality rate of 12.9%.

CONCLUSION

Coronary embolism is an under-recognized etiology of myocardial infarction with the potential for significant morbidity and mortality. To improve outcomes, physicians should strive for early diagnosis and intervention based on the underlying etiology. Thrombectomy may be considered with the goal of rapid restoration of coronary flow.

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.

Beating-heart surgical treatment of tricuspid valve papillary fibroelastoma: A case report

BACKGROUND

Cardiac papillary fibroelastomas are rare. And only 15% of the papillary fibroelastomas are located on tricuspid valve. However, the treatment of papillary fibroelastomas varies.

CASE SUMMARY

We report a 75-year-old Chinese male who was hospitalized because of a right atrial mass found by echocardiography. Complete tumor excision along with Kay's tricuspid valvuloplasty surgery on beating heart under cardiopulmonary bypass was performed to the patient. Pathologic examination confirmed the definite diagnosis of cardiac papillary fibroelastoma. The recovery of the patient was uneventful and echocardiographic examination performed 6 months after surgery revealed no recurrence of the tumor.

CONCLUSIONS

Beating-heart surgical excision is an effective and safe treatment of tricuspid papillary fibroelastomas.

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.

"Perilous pearl"--papillary fibroelastoma of aortic valve: a case report and literature review

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. These lesions are primarily responsible for embolic events that can clinically manifest with neurological and cardiovascular symptoms. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. The case of a 60-year-old man who presented with a neurological deficit caused by a papillary fibroelastoma of the noncoronary cusp of the aortic valve is described. Diagnosis was made by transesophageal echocardiogram, and the tumor was resected surgically.

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.

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.

Multiple fibroelastomas: a case report and review of the literature

Cardiac papillary fibroelastoma is a rare primary cardiac tumor that usually involves the heart valves. Multiple fibroelastomas found in a single patient is an even more rare occurrence. We describe the case of a 41-year-old woman who presented with an acute cerebrovascular accident, and was found to have 4 separate fibroelastoma tumors involving the aortic and mitral valves. The role of echocardiography in the diagnosis of this unusual tumor and its therapy is discussed.

[Papillary fibroelastoma: a rare but treatable cause of cerebral infarction]

INTRODUCTION

Papillary fibroelastoma is a benign cardiac tumor which can be associated with serious embolic complications.

EXEGESIS

We report on a 42-year-old man admitted for an ischemic stroke in the left middle cerebral artery region. Transesophageal echocardiography revealed a mitral valve tumor. Surgical excision and histological examination showed a papillary fibroelastoma. Clinical course was uneventful.

CONCLUSION

We consider the high embolic potential of this tumor, which represents a surgically treatable cause of ischemic stroke.

Papillary fibroelastoma of the aortic valve: a sudden death case of coronary embolism with myocardial infarction

Papillary fibroelastoma is a rare benign tumor, occasionally causing angina or sudden death. We report an autopsy case of an aortic valve papillary fibroelastoma with coronary artery embolism. The patient was a 68-year-old Japanese man who had collapsed suddenly in his house. He was a heavy drinker and had a history of liver disease but no notable cardiac event. The autopsy revealed extensive transmural infarction of the inferior wall of the left and right cardiac ventricles. The distal portion of the right coronary artery (segment 4, NYHA) was completely occluded by tumor emboli of the fibroelastoma. At the site of closure of the aortic non-coronary cusp, there was a typical papillary fibroelastoma, which was considered to have originated the coronary embolization.

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.

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.

Cardiac papillary fibroelastomas: rationale for excision

We experienced a case of papillary fibroelastoma of the left ventricular outflow tract in a patient with severe valvular heart disease that was detected only by transesophageal echocardiography. Preoperative detection of this lesion altered the surgical procedure to include resection of the mass through the aortic valve annulus along with repair/replacement of the valves. The literature documents sufficient morbidity/mortality to support excision of these lesions regardless of symptoms or location.