Transmitral resection of a left ventricular apical papillary fibroelastoma using video-assisted thoracoscopy

Papillary fibroelastoma in the left ventricle

We present a 61-year-old woman with a recent transient ischemic attack who presented with presyncope and was ultimately found to have a papillary fibroelastoma at the apex of her left ventricle. She underwent minimally invasive excision of the tumor.

Transapical Left Ventricular Approach for Cardiac Papillary Fibroelastomas: A Case Report

BACKGROUND/AIM

Cardiac papillary fibroelastomas (CPF) are benign tumors, frequently asymptomatic, characterized by a mobile pedunculated mass that arises from the endocardium. When CPF is located in the left ventricle, it may protrude into the left ventricular outflow tract and affect hemodynamics. They are highly thrombogenic, and can also cause some life-threatening events such as cerebral and peripheral embolization.

CASE REPORT

We herein report a case of a 74-year-old female admitted to our center with palpitations and dyspnea on exertion. Her past medical history revealed that she had had a transient ischemic attack 7 months before presentation. Echocardiography and cardiac magnetic resonance imaging revealed an intracardiac mass anchored in the anteroapical interventricular septum without interference with aortic or mitral valve functionality. Surgical resection of the left ventricular mass was performed through the left apical ventriculotomy approach. Histopathological examination of the tumor was suggestive of papillary fibroelastoma. The postoperative course was uneventful. The patient was discharged home on the eighth postoperative day, with no recurrence at 6 months.

CONCLUSION

Although left ventricular papillary fibroelastomas are benign tumors, they carry a high risk for embolic complications and therefore surgery should be proposed, the transapical approach being a safe and effective method.

A systematic review of left ventricular cardio-endoscopic surgery

Better visualisation, accurate resection and avoidance of ventriculotomy associated with use of endoscopic devices during intracardiac surgery has led to increasing interest in their use. The possibility of combining a cardio-endoscopic technique with either minimally invasive or totally endoscopic cardiac surgery provides an incentive for its further development. Several devices have been used, however their uptake has been limited due to uncertainty around their impact on patient outcomes. A systematic review of the literature identified 34 studies, incorporating 54 subjects undergoing treatment of left ventricular tumours, thrombus or hypertrophic myocardium using a cardio-endoscopic technique. There were no mortalities (0%; 0/47). In 12 studies, the follow-up period was longer than 30 days. There were no post-operative complications apart from one case of atrial fibrillation (2.2%; 1/46). Complete resection of left ventricular lesion was achieved in all cases (100%; 50/50). These successful results demonstrate that the cardio-endoscopic technique is a useful adjunct in resection of left ventricular tumours, thrombus and hypertrophic myocardium. This approach facilitates accurate resection of pathological tissue from left ventricle whilst avoiding exposure related valvular damage and adverse effects associated with ventriculotomy. Future research should focus on designing adequately powered comparative randomised trials focusing on major cardiac and cerebrovascular morbidity outcomes in both the short and long-term. In this way, we may have a more comprehensive picture of both the safety and efficacy of this technique and determine whether such devices could be safely adopted for routine use in minimal access or robotic intra-cardiac surgery.