Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation

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.

Use of Three-Dimensional Echocardiography to Identify an Unusual Cause of Aortic Regurgitation

•New-onset AR after coronary angiography should raise suspicion for AV injury. •Consider 3D imaging if no clear etiology found with 2D imaging. •Three-dimensional imaging showed a partial tear of RCC. •Medical intervention was altered based in part on TEE findings.

Papillary fibroelastoma complicated by Streptococcus sanguinis bacteremia: a rare case of cardiac tumor with embolic events

Fibroelastoma is a rare cardiac tumor that can cause embolization, stroke, myocardial infarction, heart failure, and cardiac arrest. Here, we report the case of a 45-year-old male who presented with right-sided weakness and fever. He was diagnosed with acute right frontal infarction and was found to have Streptococcus sanguinis bacteremia. Upon confirmation of a positive blood culture after 24 hours, treatment for endocarditis was initiated. Transesophageal echocardiography revealed findings highly suggestive of a papillary fibroelastoma (PFE). PFE ought to be regarded as a potential differential diagnosis in individuals who exhibit symptoms of fever, thromboembolism, and persistent bacteremia. Non-invasive imaging such as echocardiography is of great value in the diagnosis of PFE, while surgical resection remains the best treatment modality to overcome current and future associated complications.

Removal of an infected pulmonary artery fibroelastoma disguised as a presentation of pulmonary embolism using a percutaneous suction thrombectomy device

Papillary fibroelastoma (PFE) is a rare, often benign, tumor originating typically in the endocardium and valves, with a preference for the left side of the heart. Although PFEs can appear asymptomatic, in the setting of embolization, they can lead to stroke, acute limb ischemia, and/or mesenteric ischemia. Rarely, PFEs can originate from the pulmonary valve, with the potential for embolic showering into the pulmonary artery, leading to potential right-sided heart outflow obstruction. Treatment has been open surgery in most cases, although treatment of right-sided heart masses with extracorporeal circulatory support extraction systems have been described. Recently, large bore suction thrombectomy devices have become available, typically used for cases of venous thromboembolism. In the present report, we describe a case of a symptomatic infected PFE treated by percutaneous suction thrombectomy using the Inari FlowTriever system (Inari Medical).

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.

Cardiac Papillary Fibroelastoma: Atypical Presentation Mimicking Infective Endocarditis With False Positive Commensal Blood Cultures

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac neoplasms that carry a high risk of embolization if not diagnosed and managed in a timely manner. As most patients are asymptomatic, CPF may be incidentally detected on transthoracic echocardiography (TTE) when performed for other indications. Management of incidental CPF in asymptomatic patients is debatable. We report an unusual case of an incidental CPF in an asymptomatic patient admitted to the hospital for presumed infective endocarditis (IE). Two weeks following laser resection of laryngeal cancer (LC), a new pansystolic murmur was audible during a routine cardiology visit. Outpatient TTE revealed a "vegetation-like" lesion on the mitral valve (MV). Blood cultures (BC) with Gram-positive cocci in clusters (GPC) were reported within 24 hours. This prompted hospital admission for empiric antibiotics. A transesophageal echocardiogram (TEE) confirmed the lesion to be an echogenic mass attached to the MV consistent with CPF. Repeat BC, prior to empiric antibiotic initiation, were all negative. In the absence of all other signs and symptoms of IE, it was determined that the initial BC was false positive and IE was ruled out. Surgical resection was performed due to the potential risk of embolization. The pathology confirmed the diagnosis of CPF with negative tissue cultures.

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.

Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS)

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.

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.

Severe Aortic Regurgitation by Nonbacterial Thrombotic Endocarditis Treated with Anticoagulation Therapy

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NBTE often appears as vegetations attached to valves.

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Differentiating NBTE from IE is imperative as it requires different treatment.

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Valvular heart disease caused by NBTE may resolve with appropriate anticoagulation.

Cardiac Papillary Fibroelastoma: Pulmonic Valve Involvement With Pulmonary Embolism and Pulmonary Hypertension

Papillary fibroelastomas are rarely seen tumors of the cardiac valves. We present a case of papillary fibroelastoma present on the pulmonic valve. Diagnosis was made by characteristic echocardiogram findings. Complications of pulmonary embolism and pulmonary hypertension were present. Due to contraindications, the patient was managed with anticoagulation instead of surgery. 

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.

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.

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.

Surgical removal of an exceedingly rare papillary fibroelastoma of the aortic wall causing unstable angina

Difficult diagnosis is due to rarity of the case. TT or TE echocardiography is sufficient to make a correct diagnosis. The risk of embolism or coronary ostia occlusion should guide the decision for surgery.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Surgery for Valvular and Nonvalvular Papillary Fibroelastomas

Papillary fibroelastomas (PFE) are benign neoplasms, mostly located on valvular surfaces with high embolic potential. This study presents a 27-year single institutional experience on surgical treatment of PFE in an adult patient- cohort with long-term follow-up. This study was approved by the institutional review board. Date and number of IRB approval: 11/23/2017, Institutional Review Board approval number A2014-0149. The need for individual patient consent was waived. We retrospectively evaluated all patients who underwent cardiac surgery for suspected space-occupying lesions in the observation period between June 1991 and June 2018 at our hospital. Clinicopathological features, imaging characteristics, surgical procedures and disease outcome were analyzed. 120 patients were diagnosed with various primary/secondary cardiac tumors and histology confirmed 21 PFEs were found in 16 patients. There was no significant age difference between patients with valvular vs nonvalvular PFEs (P = 0.26). Valvular lesions were found in aortic valve (n = 6), mitral valve (n = 2) and tricuspid valve (n = 1). Nonvalvular PFEs were found in right atrium (n = 2), left ventricle (n = 2), left atrial appendage (n = 2) and aortic wall (n = 1). Valvular lesions were significantly smaller in size compared to non-valvular lesions (P = 0.0013). Left-side PFEs were associated with a high embolization episodes (10/13 patients, 77%) not related to the size. One patient died in-hospital. All other patients were discharged out of the hospital postoperative. Follow-up was performed regularly for a median of 2.8 years (range 0.1-11 years) postoperative. Nonvalvular PFE tended to be larger in size and at least when located on the left sided heart had equally high propensity to embolize compared to valvular PFE. We strongly advocate surgical excision in all left-sided PFE.

Recurrence of Pathologically Proven Papillary Fibroelastoma

BACKGROUND

Papillary fibroelastoma (PFE) is the most common primary benign cardiac tumor. Because PFEs have the potential to embolize, they often are surgically excised. Prior studies have suggested that postoperative recurrence of PFE is rare or does not occur. We aimed to determine the rate at which PFEs recurred after surgical removal and to identify any risk factors associated with recurrence.

METHODS

We retrospectively identified all patients from a single center with pathologically proven PFE, treated from January 1995 through December 2018. Patients were included in the study if they had an echocardiographic examination at least 1 year after surgery. We compared echocardiographic images obtained intraoperatively (after excision) and at dismissal with those of the most recent examination to assess the possibility of PFE recurrence.

RESULTS

We included 98 patients in the study. The mean (SD) duration of follow-up was 5.4 (3.7) years (range, 1-17 years); the median duration of follow-up was 4.3 years (interquartile range, 1.9-7.7 years). Twelve patients (12.2%) had echocardiographically supported PFE recurrence. Three patients had the recurrent lesion surgically re-excised, and pathologic analysis showed that 2 were recurrent PFEs and 1 was a Lambl excrescence. Initial clinical presentation of stroke or transient ischemic attack was more common for the recurrence group (for the first PFE) than for the nonrecurrence group (83% vs 26%; P<.001).

CONCLUSIONS

Contrary to findings from previous studies, PFEs do recur after surgical excision. These findings emphasize the importance of postoperative follow-up with transesophageal echocardiography for identifying recurrent masses.

A rare cause of left ventricular outflow tract mass in infancy: Cardiac papillary fibroelastoma

Primary cardiac tumors are one of the rare causes of intracardiac masses in pediatric population. Cardiac papillary fibroelastomas are benign cardiac tumors with predilection for valvular endocardium, and the presentation is dictated by the cardiac structure involved and the tumor characteristics. We report an infant with cardiac papillary fibroelastoma manifesting as an asymptomatic left ventricular outflow tract mass. This case is being presented to emphasize the rare occurrence of cardiac papillary fibroelastoma in pediatric population and to be cognizant of this entity when considering differential diagnosis of intracardiac masses in this subgroup.

Cardiac Tumors: Diagnosis, Prognosis, and Treatment

Purpose of Review

Cardiac masses frequently present significant diagnostic and therapeutic clinical challenges and encompass a broad set of lesions that can be either neoplastic or non-neoplastic. We sought to provide an overview of cardiac tumors using a cardiac chamber prevalence approach and providing epidemiology, imaging, histopathology, diagnostic workup, treatment, and prognoses of cardiac tumors.

Recent Findings

Cardiac tumors are rare but remain an important component of cardio-oncology practice. Over the past decade, the advances in imaging techniques have enabled a noninvasive diagnosis in many cases. Indeed, imaging modalities such as cardiac magnetic resonance, computed tomography, and positron emission tomography are important tools for diagnosing and characterizing the lesions. Although an epidemiological and multimodality imaging approach is useful, the definite diagnosis requires histologic examination in challenging scenarios, and histopathological characterization remains the diagnostic gold standard.

Summary

A comprehensive clinical and multimodality imaging evaluation of cardiac tumors is fundamental to obtain a proper differential diagnosis, but histopathology is necessary to reach the final diagnosis and subsequent clinical management.

Cardiac papillary fibroelastoma originating from the coumadin ridge and review of literature

Papillary fibroelastomas represent the second most common benign cardiac tumour, secondary only to cardiac myxoma. A majority of patients are asymptomatic on presentation. The most common clinical manifestations include stroke, transient ischaemic attack, myocardial infarction and angina. Echocardiography remains the primary imaging modality for identification of these tumours. The majority of papillary fibroelastomas arise from the valves. Simple surgical excision is the mainstay of treatment, carrying an excellent prognosis. We present an unusual case of cardiac papillary fibroelastoma originating from the coumadin ridge (CR) in a 70-year-old woman. The patient exhibited increasing paroxysms of her atrial fibrillation and was pursuing a MAZE procedure. Preoperatively, a transesophageal echocardiogram revealed a 0.7×1 cm intracardiac mass that had echocardiographic appearance of a fibroelastoma. Surgical resection and MAZE procedures were performed. The gross specimen and histopathology findings were consistent with papillary fibroelastoma. This case reports the seventh documented case of fibroelastoma originating from the CR.

Cardiac Imaging After Ischemic Stroke or Transient Ischemic Attack

PURPOSE OF REVIEW

Cardiac imaging after ischemic stroke or transient ischemic attack (TIA) is used to identify potential sources of cardioembolism, to classify stroke etiology leading to changes in secondary stroke prevention, and to detect frequent comorbidities. This article summarizes the latest research on this topic and provides an approach to clinical practice to use cardiac imaging after stroke.

RECENT FINDINGS

Echocardiography remains the primary imaging method for cardiac work-up after stroke. Recent echocardiography studies further demonstrated promising results regarding the prediction of non-permanent atrial fibrillation after ischemic stroke. Cardiac magnetic resonance imaging and computed tomography have been tested for their diagnostic value, in particular in patients with cryptogenic stroke, and can be considered as second line methods, providing complementary information in selected stroke patients. Cardiac imaging after ischemic stroke or TIA reveals a potential causal condition in a subset of patients. Whether systematic application of cardiac imaging improves outcome after stroke remains to be established.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

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Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

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It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

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The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

Papillary Fibroelastoma of the Right Ventricle in the Setting of Multifocal Pulmonary Hemorrhages and Pulmonary Embolization in a 39-Year-Old Man: A Case Report

Patient: Male, 39-year-old

Final Diagnosis: Papillary fibroelastoma

Symptoms: Chest pain • fever • hemoptysis • weight loss

Medication: —

Clinical Procedure: —

Specialty: Cardiac Surgery • Cardiology • Critical Care

Medicine • Pulmonology

Unusual place… unusual number

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

Cardiac papillary fibroelastomas: A 10-year single-center surgical experience and long-term echocardiographic follow-up study

AIMS

Limited contemporary data are available on the clinical and echocardiographic outcomes after surgery for cardiac papillary fibroelastoma (CPF). The aim of this study was to review the clinical manifestations, pathological characteristics, surgical management, and prognoses of patients with histologically verified CPF, who underwent surgery at our cardiac surgery center from 2008 to 2018.

METHODS AND RESULTS

Twelve patients of median age 62 years (28 to 77 years) were treated. Embolic stroke or transient ischemic attack (five patients, 42%) were the only CPF clinical manifestations. Eleven (92%) tumors were localized on the valves, with the aortic valve being the most common tumor site (seven patients; 58%). Multiple factor analysis revealed no independent predictor of CPF-related embolization. Simple shave tumor excision was sufficient in most patients (10 patients, 83%). No operative or tumor-related late mortality during the median follow-up period of 4.7 years (1.1 to 10.2 years) was recorded. Asymptomatic metachronous valve tumor recurrence (in a location different from that of the original tumor) was revealed in two patients (17%) by transesophageal echocardiography (TEE), not detected by transthoracic echocardiography (TTE). One of these two patients underwent repeated surgery for CPF but later suffered a recurrent embolic stroke, due to another tumor recurrence.

CONCLUSION

CPF can be safely and effectively treated surgically. TEE is superior to the TTE option in CPF post-operative recurrence detection. There is a clear need for a prospective study to determine criteria for embolization risk stratification and optimum management in patients with CPF.

Cardiac imaging after ischemic stroke : Echocardiography, CT, or MRI?

About 20–25% of all ischemic strokes are of cardioembolic etiology, with atrial fibrillation and heart failure as the most common underlying pathologies. Diagnostic work-up by noninvasive cardiac imaging is essential since it may lead to changes in therapy, e.g., in—but not exclusively—secondary stroke prevention. Echocardiography remains the cornerstone of cardiac imaging after ischemic stroke, with the combination of transthoracic and transesophageal echocardiography as gold standard thanks to their high sensitivity for many common pathologies. Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source of stroke is suspected. However, to date, there is no proven benefit of transesophageal echocardiography-related therapy changes on the main outcomes after ischemic stroke. Based on the currently available data, cardiac computed tomography and magnetic resonance imaging should be regarded as complementary methods to echocardiography, providing additional information in specific situations; however, they cannot be recommended as first-line modalities.

Fibroelastoma in an unusual location: a rare cause of multiple cerebrovascular events

Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source.

An atypical cause of myocardial infarction: case report of an obstructing papillary fibroelastoma of the aortic valve

BACKGROUND

Papillary fibroelastomas are rare primary cardiac tumours with a prevalence of 0.01% at autopsy. They are histologically benign tumours but have been demonstrated through case series to confer an increased risk of thrombo-embolism resulting in: transient ischaemic attack, stroke, myocardial infarction, and pulmonary and systemic embolization.

CASE SUMMARY

A 54-year-old woman presented with central chest pain radiating to her left arm. At presentation there was a significant troponin rise; initial high-sensitivity troponin-I (hsTn-I) 660 pg/mL increased to 3340 pg/mL at 6 h. Coronary angiogram did not reveal any obstructing coronary artery disease. Echocardiography revealed a rounded, mobile mass on the left coronary cusp of the aortic valve suspicious for papillary fibroelastoma. The patient underwent shave excision of the lesion. Intra-operatively it was noted that the mass intermittently sat within the ostium of the left main resulting in its occlusion. Histology confirmed a papillary fibroelastoma.

DISCUSSION

Primary cardiac tumours are rare but can cause life-threatening complications such as stroke, myocardial infarction, and cardiac arrest. In the literature, the mechanism of these complications is mainly attributed to thrombo-embolism. This case demonstrates the utility of echocardiogram in investigating and diagnosing a rare cause of myocardial infarction and highlights an unusual mechanism, that is tumour causing obstruction of the coronary ostium.

A Case of Fibroelastoma with Widespread Embolism to the Brain, Kidney, and Spleen

Cardiac papillary fibroelastoma (CPF) is the second most common primary cardiac tumor, which is diagnosed incidentally or with embolic phenomena, mostly in the form of a transient ischemic attack (TIA) and stroke. We present a case of a 58-year-old female who presented with fatigue and low-grade fever and was found to have multiple systemic infarcts. Her blood cultures and transthoracic echocardiography (TTE) were negative, ruling out infective endocarditis. However, transesophageal echocardiography (TEE) revealed a mobile mass at the aortic valve. The mass was surgically removed, and the aortic valve was repaired. The histological examination of the mass finally revealed a papillary fibroelastoma. To our knowledge, this is the first reported case where fibroelastoma presented with splenic and renal infarcts in combination with the cerebral infarcts. Since cardiac fibroelastoma can cause embolization to the cerebral, splenic, and renal vessels, we, therefore, advocate that it should be considered as one of the possible causes of widespread embolism. We also stress upon the importance of doing TEE in case of a suspected cardiac mass, as the TTE is more likely to give false-negative results.

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

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

[Cardiac papillary fibroelastoma and stroke during pregnancy: Case report]

Stroke occurring during pregnancy is linked to high mortality. Stroke may be directly related to pregnancy (e.g. eclampsia, cerebral venous thrombosis), but all the other causes of stroke are possible. Brain magnetic resonance imaging that is not contraindicated during pregnancy remains the reference in this context. We report the case of a woman with severe headache associated with visual disturbances, without hypertension or proteinuria at 32 weeks of pregnancy. MRI revealed multiple recent cerebral vascular accidents. An echocardiogram detected a papillary fibroelastoma of 5mm. Maternal fetal experts determined it safe to continue the pregnancy. Childbirth at 39 weeks was normal uneventful for the newborn and mother. In the postpartum, despite the theoretical operative indication to resect the small residual papillary fibroelastoma, the patient was followed expectantly because of the stable neuro-cardiologic state. A fibroelastoma can be revealed by a stroke during pregnancy. In the postpartum period, an expectant attitude can be reasonably chosen in case of small size of the fibroelastoma.

Left atrial appendage mass

Left atrial (LA) masses are known to be associated with peripheral embolization. Accurate identification of etiology is crucial because treatment strategies may differ. We present the case of a young woman, who was initially diagnosed with a LA thrombus and anticoagulated. The diagnosis was revised to a primary cardiac tumor after review of the echocardiographic findings. Surgical excision revealed an atrial myxoma in an unusual location.

Contrast Echocardiography without Contrast Agent for Display of Intraventricular Mass

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Contrast echocardiography was scheduled for assessment of a cardiac mass.

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A bright mass was displayed using very low MI contrast-specific imaging.

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Histologic examination showed a papillary fibroelastoma.

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Low-MI contrast imaging may help diagnose tumors with high content of fibrous tissue.

A Left Ventricular Papillary Fibroelastoma Presenting as an Acute Coronary Syndrome

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PFEs are benign cardiac tumors with possible catastrophic embolic complications.

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Echocardiography is the initial modality of choice in their diagnosis.

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Surgical excision is warranted in symptomatic cases or if embolization is likely.