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

Transaortic Excision of Left Ventricular Papillary Fibroelastoma

Transthoracic echocardiography in a 75-year-old woman with fatigue, dizziness, and left-sided weakness, demonstrated a 3.5 × 3-cm mass in the left ventricle, near the apex. The mass was excised via the aorta. Histology indicated a papillary fibroelastoma. Such tumors rarely arise from the ventricular endocardium.

Papillary fibroelastoma of the mitral valve chordae with systemic embolization

Papillary fibroelastoma (PFE) is a rare benign tumor that most commonly involves heart valves. Cardiac PFE involving the mitral chorda is rarer. Most papillary PFE are asymptomatic; rarely, they are diagnosed because of cardiac symptoms or after an embolic event. In this case, a 70-year-old woman presented with an acute cerebral ischemic infarct. Evaluation for potential embolic source revealed a mass on the mitral chordae. The findings of cardiac magnetic resonance (CMR) tissue characterization of the mass corroborated the diagnosis of mitral valve tumor. She underwent surgical resection of this mass and histology, which confirmed a PFE. <Learning objective: PFE are easily detected on echocardiography but are difficult to visualize with CMR. Their small size and rapid, extensive movement render adequate CMR imaging extremely difficult. This case highlights the ability of CMR to characterize the tissue characteristics and enhancement pattern which enables non-invasive assessment for the etiology of intra-cardiac masses and usually distinguishes a tumor from thrombus.>.

A colossal atrial myxoma

Atrial myxomas are the most common benign primary tumor of the heart. These cardiac growths can masquerade as mitral stenosis and infective endocarditis. A 35-year-old man presented with complaints of nonspecific symptoms. Echocardiogram revealed a large atrial myxoma occupying the left atrium. Excision revealed a 14 × 8 × 6 cm3 tumor attached to a 4 × 3 × 2 cm3 stalk of septal tissue. We describe a giant left atrial myxoma. We were not able to find another myxoma as big as this one in the literature, so we are reporting it.

Splenic infarction associated with a mobile aortic valve lesion: a case report and review of the literature

The present report describes a 67-year-old woman with a mobile aortic valve lesion discovered by transesophageal echocardiography performed in the setting of abdominal pain. Definitive identification of the lesion was not possible by transesophageal echocardiography alone. Pathological examination of the excised lesion led to the diagnosis of papillary fibroelastoma (PFE). PFEs are rare benign tumours that primarily affect cardiac valves. Because left-sided PFEs are associated with a high risk of systemic embolization including cerebral ischemia and myocardial infarction, they require preventive surgical correction. The present case of PFE is reviewed for a better understanding of its pathology.

Cardioembolic stroke due to papillary fibroelastoma

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

Cardiac papillary fibroelastoma of the mitral chorda

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

Papillary fibroelastoma as an accidental finding in a multislice computed tomography of coronary arteries

Papillary fibroelastomas represent less than 10% of all primary cardiac tumours. They are usually incidental autopsy or surgical findings, or detected during echocardiography or catheterization. The case of a 58-year-old man with typical exertional chest pain hospitalized for an elective multislice computed tomography (MSCT) scan of the coronary arteries is described. The MSCT scan showed a pathological, mobile lesion within the aorta lumen only, not obstructing the ostia of the coronary arteries, and was confirmed by echocardiography. The typical features of the tumour in the MSCT scan and on echocardiography were the basis for the diagnosis of papillary fibroelastomas in the patient. Surgical excision was proposed, but the patient declined.

Cardiac papillary fibroelastoma presents as an acute embolic stroke in a 35-year-old African American male

This is an interesting case of a young patient suffering an acute embolic stroke in the middle cerebral artery distribution, who was later found to have a papillary fibroelastoma on the mitral valve. The mass was first recognized by transesophageal echocardiography and eventually resected surgically. The retrieved specimen had classic histologic findings of a papillary fibroelastoma. A thrombus was noted on the tip of the specimen, supporting the theory that these masses are risks for strokes secondary to damage along the endothelial lining predisposing to subsequent fibrin deposition and mural thrombus formation.

Papillary fibroelastoma of the mitral valve associated with rheumatic mitral valve stenosis

With the advent of echocardiography, diagnosis of papillary fibroelastoma in living patients has been made possible, yet papillary fibroelastoma found in the living remains a very rare cardiac tumor. We report a case of papillary fibroelastoma of the mitral valve with rheumatic mitral valve stenosis. A 68-year-old woman was referred to our hospital with a mitral valve tumor and rheumatic mitral valve stenosis. She underwent anticoagulation therapy with Warfarin for 8 years since having a cerebral embolization. Echocardiography revealed a mass attached to the mitral valve, with severe mitral valve stenosis. Electrocardiography demonstrated a chronic atrial fibrillation. Tumor excision with mitral valve replacement and maze procedure were performed. Both the surgical and histological findings depicted papillary fibroelastoma. The postoperative course was uneventful and the patient has remained symptom-free one year after surgery.

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.

An unusual case of multiple papillary fibroelastoma, review of literature

Primary neoplasms of the cardiac valves are extremely rare. However, papillary fibroelastoma is the third most common primary tumor of the heart [Ann Thorac Surg 52 (1991) 1127]. These tumors can be found anywhere in the heart, but most commonly involve the cardiac valves [Ann Thorac Surg 52 (1991) 1127; McAllister HA, Fenoglio JJ. Tumors of the cardiovascular system. In: Atlas of tumor pathology, 2nd series, vols. 1-3. Washington (DC): Armed Forces Institute of Pathology; 1978. p. 20-5]. Most papillary fibroelastomas do not cause symptoms and are usually incidental findings by routine echocardiography or at autopsy. However, early diagnosis of this condition is important, since it represents a surgically correctable cause of systemic emboli, stroke, myocardial infarction, and sudden cardiac death [Ann Thorac Surg 52 (1991) 1127; Ann Thorac Surg 68 (1999) 1881; J Am Soc Echocardiogr 9 (1996) 353; Tex Heart Inst J 22 (1995) 327; Tex Heart Inst J 26 (1999) 298]. The echocardiographic findings should be confirmed by histology, since the clinical differential diagnosis includes myxoma, vegetation, thrombi, lipoma, and pseudopapillary fibroelastoma [Tex Heart Inst J 26 (1999) 298; J Am Soc Echocardiogr 11 (1998) 92; J Natl Med Assoc 87 (1995) 68]. Review of the literature reveals that multiple papillary fibroelastomas are extremely rare [Am Heart J 125 (1993) 1443; J Am Soc Echocardiogr 7 (1994) 315; Ann Thorac Surg 48 (1989) 119]. Li Manduri et al. [J Am Soc Echocardiogr 7 (1994) 315] reported multiple masses on the tricuspid valve, the larger of which was 1 cm in diameter. De Virgilio et al. [Ann Thorac Surg 48 (1989) 119] reported a case of multiple 1-cm papillary fibroelastomas located on mitral valve, left ventricular outflow tract, and along septum. We report an unusual case of multiple papillary fibroelastomas in a woman, who initially was admitted because of a shortness of breath and recent cerebrovascular accident.

Cardiac papillary fibroelastoma originating from pulmonary vein--a case report

Cardiac papillary fibroelastoma is a primary cardiac neoplasm that typically affects the cardiac valves, mainly the aortic and mitral valves, and very rarely the endocardium of cardiac chambers. Cardiac papillary fibroelastoma is rarely diagnosed during life, as the majority are incidental findings at autopsy, but with the advent of echocardiography, it is being increasingly recognized. Although the tumor is usually small and histologically benign, it may have a malignant propensity for life-threatening complications, such as a cerebrovascular accident, myocardial ischemia or infarction, or sudden death. The patient reported here presented with an embolic stroke from a thrombus on the surface of a left atrial papillary fibroelastoma. The papillary fibroelastoma was originating from the lower portion of the left inferior pulmonary vein and was protruding into the left atrial cavity. Papillary fibroelastoma originating from the pulmonary veins has not been reported before. The tumor was successfully removed by intraoperative transesophageal echocardiography-guided cardiac surgery. Grossly, the surface of the tumor was smooth and translucent. The gelatinous membrane on the surface tore easily, and soft papillary tumor with multiple fronds was visible. Histology confirmed the mass was a papillary fibroelastoma. Postoperative recovery was uneventful. Follow-up transthoracic echocardiogram revealed no residual or recurrence of tumor. The patient was in excellent health at 2-year follow-up. The case is described and the clinical characteristics of cardiac papillary fibroelastoma are reviewed.

Papillary fibroelastoma of a mitral valve chorda

A 43-year-old woman presented with an ischemic stroke in the right middle cerebral artery territory. Cardiac echography disclosed a tumor of a primary chordae of the anterior leaflet of the mitral valve. After neurologic recovery, the patient was referred to surgery for excision of the tumor and plastic reconstruction using a chordal transfer technique. Histological examination of the tumor showed a typical papillary fibroelastoma. Papillary fibroelastoma is the third most frequent cardiac benign tumor. The high embolic potential of this tumor is in favor of an aggressive surgical attitude.

Papillary fibroelastoma of the left atrial appendage: echocardiographic findings

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

Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation

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

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

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

CASE REPORTS

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

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.

Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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