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.

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.

A Case of Rapidly Growing Tricuspid Valve Papillary Fibroelastoma Presenting With Syncope

Cardio-oncology, at the intersection of cardiovascular diseases, oncological conditions, and treatments, presents unique challenges in medical care. This abstract highlights a case involving a 60-year-old male presenting with syncope at work; the workup revealed a rapidly growing tricuspid valve papillary fibroelastoma (PFE), emphasizing diagnostic approaches, management strategies, and clinical implications. The diagnostic investigation, including blood cultures, transthoracic echocardiogram, transesophageal echocardiogram, and cardiac MRI, confirmed the diagnosis of tricuspid valve PFE. A multidisciplinary approach led to a shared decision with the patient to opt for serial monitoring. Syncope was attributed to dehydration. This case underscores the complexities of managing cardiovascular conditions in the context of oncology and the importance of collaborative decision-making in patient care.

Massive Mysteries

Papillary fibroelastomas are benign masses often originating from the endocardium of the aortic and mitral valves. Rarely, these neoplasms are found in areas of the heart embryonically distinct from the aortic and mitral valves. Diagnosis of a papillary fibroelastoma relies on multimodal imaging as well as histologic assessment. A case series of papillary fibroelastomas in unusual locations is presented, highlighting the role of multimodal imaging techniques in identifying these intra-cardiac masses. Differential diagnoses, imaging characteristics, histopathology, and preferred management strategies for cardiac masses are reviewed. The unique imaging qualities of cardiac masses are discussed.

Minimally Invasive Extirpation of Benign Atrial Cardiac Tumors: Clinical Follow-Up and Survival

OBJECTIVE

Evidence determining the optimal treatment for cardiac tumors is rare. We report our midterm clinical outcome and patient characteristics of our series undergoing atrial tumor removal through a right lateral minithoracotomy (RLMT).

METHODS

From 2015 to 2021, 51 patients underwent RLMT for atrial tumor extirpation. Patients receiving concomitant atrioventricular valvular, cryoablation, and/or patent foramen ovale closure surgery were included. Follow-up was performed using standardized questionnaires (mean: 1,041 ± 666 days). Follow-up involved any tumor recurrence, clinical symptoms, and any recurrent arterial embolization. Survival analysis was successfully achieved in all patients.

RESULTS

Successful surgical resection was achieved in all patients. Mean cardiopulmonary bypass and cross-clamping times were 75 ± 36 and 41 ± 22 min, respectively. The most common tumor location was the left atrium (n = 42, 82.4%). Mean ventilation time was 12.74 ± 17.23 h, intensive care unit stay ranged from 1 to 1.9 days (median: 1 day). Nineteen patients (37.3%) received concomitant surgery. Histopathological analysis showed 38 myxoma (74.5%), 9 papillary fibroelastoma (17.6%), and 4 thrombus (7.8%). Thirty-day mortality was observed in 1 case (2%). One patient (2%) suffered a stroke postoperatively. No patient had a relapse of cardiac tumor. Three patients (9.7%) showed arterial embolization during follow-up. Thirteen follow-up patients (25.5%) were in New York Heart Association class ≤II. Overall survival was 90.2% at 2 years.

CONCLUSIONS

A minimally invasive approach for benign atrial tumor resection is effective, safe, and reproducible. Of the atrial tumors, 74.5% were myxoma and 82% were located in the left atrium. A low 30-day mortality rate with no manifestation of recurrent intracardiac tumor was observed.

Left Ventricular Papillary Fibroelastoma

INTRODUCTION

Cardiac papillary fibroelastoma is a rare benign primary cardiac tumor typically found on the valvular structures of the heart. Nonvalvular papillary fibroelastomas are exceedingly rare. We report the case of a 66-year-old male who presented with cerebellar infarctions and was found to have a mobile mass attached to the endocardial surface of the anteroseptal wall of the left ventricle. Cardiac magnetic resonance imaging demonstrated late gadolinium enhancement. Surgical excision of the cardiac mass was performed via the transaortic approach without intra-operative complications. Histopathologic examination confirmed the diagnosis of a papillary fibroelastoma. Some aspects related to the etiology, diagnosis and management of this entity are discussed.

Nonbacterial Thrombotic Endocarditis of the Mitral Valve With Echocardiographic Appearances Mimicking a Papillary Fibroelastoma in a Middle-Aged Female Patient

Papillary fibroelastoma (PFE) and nonbacterial thrombotic endocarditis (NBTE) account for <1% of all cardioembolic strokes. When there is no evidence of infection, and an exophytic valve lesion is seen on echocardiography, PFE may be an initial imaging diagnosis. NBTE, or Libman-Sacks endocarditis, is a rare entity and can present with varied imaging findings. This report presents a case of embolic stroke and NBTE mimicking a PFE. We discuss a 49-year-old female with a past medical history of diabetes mellitus who presented with headache and right-hand numbness. The initial CT head was negative and the MRI brain showed multiple infarcts in the watershed areas where anterior and posterior brain circulation meet and overlap. A transesophageal echocardiogram (TEE) showed a left ventricle (LV) mass initially diagnosed as PFE. The patient was started on aspirin only with no anticoagulation since we thought the stroke was related to an embolus from a tumor, not a thrombus. The patient underwent surgery but the pathology report revealed a diagnosis of organizing thrombus with abundant neutrophilic infiltration and no neoplastic proliferation. This case report highlights the importance of a comprehensive evaluation of valvular masses and the diagnostic approaches currently available to help clinicians differentiate between various causes of embolic stroke like PFE, bacterial endocarditis, and NBTE. Early differentiation is critical because it can affect the treatment and outcome. This report shows that echocardiography of endocardial and valvular lesions may provide a differential diagnosis, but a definitive diagnosis requires microbiology and histopathology. Advanced imaging techniques such as cardiac CT or cardiac MRI may assist in identifying select cases that are at lower risk for subsequent embolic events, in which surgical intervention may safely be avoided.

Robot-Assisted Resection of Left Ventricular Papillary Fibroelastoma Arising From the Mitral Chordal Apparatus

The application of robot-assisted thoracoscopy to cardiac surgery affords an opportunity to leverage the exceptional intraoperative exposure, visualization, and dexterity of the robotic platform. Here, we report the case of a 72-year-old woman who presented to our institution for evaluation of a left ventricular mass that was identified following workup for an embolic event. We present an intraoperative video that provides technical details of the robot-assisted resection of the lesion, which was found to be a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus. This case highlights the advantages provided by the robotic platform, which permitted complete, minimally invasive surgical excision of the lesion while minimizing the burden of surgical trauma.

Very Mobile Left Ventricular Outflow Tract Papillary Fibroelastoma Presenting with Multiple Ischemic Strokes: A Case Report and Brief Review of the Literature

Papillary fibroelastomas (PFs) are small and pedunculated left side valves associated mass, that frequently causing cerebral embolization. We present the case of a 69-year-old male with a history of multiple ischemic strokes and a small pedunculated mass in the left ventricle outflow tract, highly suggestive of a rare case of PF in an atypical localization. Due to the clinical history and the echocardiographic aspect of the mass, he underwent surgical excision and Bentall intervention for concomitant aortic root and ascending aorta aneurysm. The pathological analysis of the surgical specimen confirmed the diagnosis of PF.

Papillary fibroelastoma revealed by an acute coronary syndrome with transient ST segment elevation: a case report

Cardiac papillary fibroelastoma is a rare, benign tumour, arising from the valvular endocardium, which could lead to life-threatening complications as myocardial ischemia. We report a case of a 54-year-old male patient who presented in the emergency room with an acute coronary syndrome with transient ST segment elevation. After ruling out coronary artery disease by coronarography, we established the diagnosis of papillary fibroelastoma by performing echocardiogram completed by computed tomography angiography. The reversible acute coronary syndrome has been caused by the prolapse of pedunculated coronary cusp tumour into the main left coronary ostium. The patient was scheduled for emergent surgery. The surgical management included a complete resection of the tumour sparing the aortic valve. The patient recovered well. A papillary fibroelastoma of the aortic valve can be revealed by an acute coronary syndrome with transient ST segment elevation. More investigations must be done to eliminate such diagnosis in the case of a normal coronarography.

Cardiac Papillary Fibroelastoma: A Rare Cause of Cardioembolic Stroke

BACKGROUND

Cardiac fibroelastomas are exceedingly rare etiologies of stroke, increasingly recognized with better diagnostic modalities. Surgical excision is the only curative option; however, timing of heparinization for cardiac bypass remains a challenging decision.

OBJECTIVE

We present a case of a 56-year-old female, diagnosed with multiple posterior circulation strokes and a left atrial mass, who successfully underwent anticoagulation and resection in 1 week.

MATERIAL AND METHODS

MRI of the brain demonstrated numerous embolic-looking posterior circulation strokes. Transthoracic echo was negative for atrial pathology; a transesophageal echo revealed a left atrial mass, histologically consistent with papillary fibroelastoma.

RESULTS

Resection was delayed for up to 1 week to allow safe heparinization. We present a unique case of embolic stroke of undetermined source (ESUS) arising from a histologically rare tumor.

CONCLUSION

We make the case for extensive workup for evaluation of posterior circulation strokes, including TEE, as well as timely resection of cardiac tumors.

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.

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.

Discovery of Tricuspid Fibroelastoma on Echocardiography

Papillary fibroelastoma (PFE) is a benign cardiac tumor usually incidentally found on cardiac imaging. They are typically located on the left-sided heart valves and are concerning primarily due to their risk for embolization into the periphery. Right-sided PFE, however, is very rare and their management is not well known. We present a 66-year-old male with a past medical history of HIV on antiretroviral therapy presenting with new exertional dyspnea. Upon workup, he was found to have a mass on the tricuspid valve seen on echocardiography which was ultimately resected and found to be a tricuspid fibroelastoma. The clinical management of right-sided PFE is poorly documented. Treatment of PFE in an asymptomatic is dependent on characteristics such as location, mobility, and risk of embolization. Echocardiography has made the incidental diagnosis of PFE a common issue in asymptomatic patients such as ours.

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.

Case Report: Multimodality Imaging as a Lifeline for Fatal Localization of Valsalva Sinus Fibroelastoma

Background: Papillary fibroelastomas are rare benign heart tumors, and is most likely to involve the cardiac valves. We will present an extremely rare localization of a large Valsalva sinus fibroelastoma, with occasional left coronary artery ostial obstruction presented as an acute coronary syndrome. The tumor was removed surgically and histologically confirmed as papillary fibroelastoma. This review points to the crucial importance of multidisciplinary team decision and multimodality imaging methods for diagnosing the fibroelastoma, determination of size, and localization, which avoided complications of fatal embolization during an invasive procedure.

Case Summary: A healthy 55-year-old male with vigorous physical daily training and exercise was admitted to the acute coronary syndrome emergency department. Shortly after admission, expert transthoracic echocardiography was performed. Computed tomography of the chest observed a large irregular hypodense tumor-like lesion in the bulbar aorta that was occasionally prolapsing into the left main coronary artery ostium and which corresponded to fibroelastoma. A few hours after admission, an emergency cardiac surgery was performed with the excision of a Valsalva sinus tumor (size 2 × 2 cm) located between the right and left coronary cusp of the aortic valve.

Conclusions: Focus cardiac ultrasound should be performed for any acute coronary syndrome because of the possible Valsalva sinus fibroelastoma etiology. Its localization next to the left main coronary artery ostium is rare, and dangerous. The timely diagnosis can be made by the multimodality imaging method, however, the final diagnosis will be made pathohistologically. Early cardiac surgery may be a necessitated recourse for these patients in order to prevent a fatal outcome.

Case Report: A Rare Case of Right-Sided Papillary Fibroelastoma in a 1-Year-Old With Congenital Heart Disease

Introduction: Cardiac papillary fibroelastomas (PFEs) are the most common primary benign cardiac tumors, although they are somewhat unusual in children and typically seen on the left-sided cardiac valves. Case summary: A 10-week-old patient was found to have a partial atrioventricular canal defect, with associated tricuspid and mitral regurgitation. He was medically managed until 1 year of age, when surgical correction was done. During the procedure, a PFE was found incidentally on the TV. Conclusion: This is one of the youngest patients to be reported with PFE, thus adding to the literature of these unusual cases in children.

Coronary embolization from aortic valve fibroelastoma

Papillary fibroelastomas have a range of clinical presentations. The surgical removal of these tumors should always be considered as best alternative to a conservative approach.

A rare case of a pulmonary valve papillary fibroelastoma

CASE

A 67-year-old female presented with an exceedingly rare cardiac neoplasm - papillary fibroelastoma. This is made rarer still as it occurred on the pulmonary valve. The patient complained of a prolonged history of chest discomfort. Magnetic resonance imaging and echocardiography revealed a pulmonary valve papillary fibroelastoma. Surgical excision proved curative and the patient remains asymptomatic to date.

DISCUSSION

The literature surrounding papillary fibroelastomas is discussed. Primary cardiac tumours are uncommon. Papillary fibroelastomas occurring the right side of the heart comprise less than 0.05% of these. They have a characteristic macroscopic appearance which allow them to be easily identified with echocardiography and at surgical excision. They can present in a variety of ways including classical cardiac symptoms, embolic complications or as an incidental finding. Surgical excision is the definitive treatment.

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.

•

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.

•

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

•

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

The Right Anterior Thoracotomy Approach to Resect a Cardiac Papillary Fibroelastoma of the Aortic Valve

A cardiac papillary fibroelastoma (CPFE) is reported to be the second most common cardiac neoplasm after myxoma cordis. CPFEs are histologically benign, frequently asymptomatic, but highly thrombogenic, which could lead to systemic and peripheral embolization. We present a case of a 68-year-old-patient, with a history of angioosteohypertrophy syndrome, who presented at our emergency department (ED) with symptoms of transient ischemic attacks. A thorough investigation, including echocardiography, revealed a neoplasm on the left coronary cusp (LCC) of the aortic valve. The neoplasm was resected via a valve-sparing shave via the right anterior thoracotomy (RAT). The pathological assessment confirmed it to be CPFE. CPFE is a rare but treatable cause of thromboembolism. The removal of CPFEs has classically been performed through a full median sternotomy. We like to present the first case of a valve-sparing removal of a CPFE on the aortic valve through a RAT approach.

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 fibroelastoma arising from the opening of the left inferior pulmonary vein in left atrium: A rare case report

RATIONALE

Cardiac papillary fibroelastoma is a small, benign endocardial tumor, while it is clinically important because of its strategic position and propensity for causing embolic events and hemodynamic complications.

PATIENT CONCERNS

A 59-year-old female presented our hospital for investigation and treatment of a sudden onset of syncope lasted about 2 minutes.

DIAGNOSES

Cardiac papillary fibroelastoma arising from left inferior pulmonary vein in left atrium.

INTERVENTIONS

The tumor was successfully removed by cardiac surgery.

OUTCOMES

The patient's postoperative course was uneventful, and she was discharged 10 days after surgery. The patient remained free of neurologic deficits and had no evidence of residual or recurrence of tumor with echocardiography during 1 year of follow-up.

LESSONS

Cardiac papillary fibroelastoma is a benign tumor, with increased risk of thromboembolic events. It is often diagnosed in patients with echocardiography by chance or after a neurologic event. Complete surgical resection should be considered when the patient is indicated and the long-term postoperative prognosis is excellent.

Incidental finding of an asymptomatic pulmonary valve papillary fibroelastoma: A case report

Primary cardiac tumors are rare, but papillary fibroelastoma (PFE) is reportedly the most common form, which usually occurs on the left-side valves of the heart. However, PFE involving the tricuspid and pulmonary valves has also been documented. Although PFE is benign and seldom associated with valvular dysfunction, the associated embolic complications may lead to serious consequences. Most patients with PFE lack specific clinical symptoms and the diagnosis is incidental. Surgical resection is the mainstay treatment for PFE in order to prevent the occurrence of embolic complications. In this report, we present a case of a rare asymptomatic PFE of the pulmonary valve, which was incidentally noted during a routine examination with transthoracic echocardiography (TEE). There was neither valvular dysfunction nor hemodynamic change. The PFE was surgically removed, and the diagnosis was further confirmed with histopathology.

Giant Tricuspid Valve Fibroelastoma Incidentally Diagnosed During Routine Stress Testing

Papillary fibroelastomas (PFEs) are the most common valvular tumor, typically occurring on left-sided valves. We describe the evaluation and treatment of a giant tricuspid PFE in a healthy 43-year-old police officer who was referred for evaluation of frequent premature ventricular contractions during job-related treadmill stress testing. (Level of Difficulty: Beginner.).

Papillary fibroelastoma in the left atrium

Described herein is a 71-year-old woman with previous angina pectoris who suddenly developed slurred speech and right-arm weakness. She was found to have significant coronary narrowing, a small mass in the left atrium attached to the endocardium near the orifice of the appendage, and multifocal punctate cerebral lesions in the distribution of the left middle cerebral artery. The left atrial mass was excised and confirmed to be a papillary fibroelastoma. Coronary bypass was also performed. It is believed that fibrin thrombus developed within the fronds of the fibroelastoma and embolized to the brain. Such lesions in the left atrium are exceedingly uncommon. She had no further emboli events.

Cerebral Embolism due to a Large Papillary Fibroelastoma arising from the Coumadin Ridge

A 70-year-old woman developed acute cerebral infarction. Transthoracic echocardiography showed a large mobile mass in the left atrium, suggesting cardiac myxoma as the most likely diagnosis. Surgical exploration revealed a papillary fibroelastoma originating from the coumadin ridge, which is fairly rare but important as a source of cerebral embolization.

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.

Pulmonary Eosinophilic Inflammatory Infiltration Post-Intensive Care in a Nearly Drowned Young Man with Papillary Fibroelastoma: A Rare Complication Discovered by Forensic Autopsy

Papillary fibroelastoma is a rare benign lesion of heart (1). It is the second most common primary cardiac neoplasm, accounting for 4.4-8% of all tumors of the heart (2). We described a forensic autopsy of a nearly drowned young man with cardiac papillary fibroelastoma who died because of a pulmonary inflammatory infiltration rich in granulocytes after intensive care. This occurrence is rare but possible and should be kept in mind because a lung inflammatory infiltrate rich in eosinophilic granulocytes can be present in different pathological conditions and differential diagnoses are often difficult to do.

An aortic valve papillary fibroelastoma: A case report

Papillary fibroelastomas are rare tumors of the heart, mostly involving the valves. They can be asymptomatic and diagnosed incidentally or they can cause life-threatening clinic scenarios including cerebrovascular accidents, coronary arterial occlusions, or peripheral embolisms. Papillary fibroelastomas can be easily excised surgically using valve sparing techniques with low complication rates and without recurrence. In this report, we present a case of papillary fibroelastoma which was found incidentally before coronary artery bypass grafting operation and successful removal of the lesion with a valve sparing approach.

Histology of Thrombectomy Specimen Reveals Cardiac Tumor Embolus in Cryptogenic Young Stroke

A 25-year-old woman presented with acute onset of right hemiplegia and global aphasia with National Institutes of Health Stroke Scale score of 19. Computed tomography angiography demonstrated occlusion of the left proximal middle cerebral artery. She was thrombolysed with intravenous recombinant tissue plasminogen activator (0.6 mg/kg) within 3 hours of onset of symptoms and was taken up for mechanical thrombectomy. The retrieved specimen appeared pale white and soft; histopathologic examination revealed a papillary neoplasm composed of papillae with hyalinized cores lined by endothelium, consistent with papillary fibroelastoma of cardiac origin. Transesophageal echocardiography showed no abnormalities, which can be explained by complete embolization of the mass into the cerebral circulation. On follow-up after 5 months, the patient recovered with only minimal aphasia and no cardiac symptoms. Our experience with this case highlights the importance of histopathologic examination of the mechanical thrombectomy specimen, as it provided the only clue to the etiology of stroke.

Papillary Fibroelastoma Found With Transesophageal Echocardiography After a Normal Transthoracic Echocardiography

We present the case of a patient with transient ischemic attacks who was being investigated for multiple embolic strokes. Initial workup, including brain computed tomography, computed tomography angiography, and transthoracic echocardiography (TTE) were negative for a source until transesophageal echocardiography (TEE) found a mass in the left atrium. The TEE differentiated the mass as a rare cardiac papillary fibroelastoma on the left atrial free wall confirmed by postsurgical pathology. This case highlights the importance of TEE as a diagnostic tool for its ability to more accurately differentiate and characterize the tumor compared with TTE. This case underscores that a negative TTE does not equate to zero risk of the presence of a cardiac tumor. It is prudent for the clinician to be cognizant that it may be beneficial to perform a TEE even with a negative TTE workup.

Aortic valve replacement for papillary fibroelastoma

Surgery is indicated for symptomatic patients with papillary fibroelastomas (PFE) on the aortic valve. The valve is commonly spared during tumor excision. Rarely, aortic valve replacement (AVR) is needed. We present a case requiring AVR for an aortic valve PFE and review the literature to determine the risk factors for failure of aortic valve-sparing techniques in patients with PFE.

Incidental tricuspid valve fibroelastoma associated with patent foramen ovale in a young female: Straightforward diagnosis but controversial management

Papillary fibroelastoma is an uncommon primary cardiac tumor, predominantly associated with left-sided valvular endocardium. Affectation of tricuspid valve leaflets is rare, and management in asymptomatic patients remains controversial. We present a 30-year-old female referred for evaluation prior to bariatric surgery. A routine echocardiogram revealed a mobile cardiac mass attached to the tricuspid valve. A patent foramen ovale was also present. Tumor was surgically removed. Histology confirmed the definite diagnosis of a papillary fibroelastoma. In our case, the presence of a patent foramen ovale associated with the right-sided fibroelastoma was decisive in the decision for surgery.

KRAS mutation in papillary fibroelastoma: a true cardiac neoplasm?

Primary cardiac tumours are rare and mostly benign lesions. Recent publications report that cardiac papillary fibroelastomas are the most common benign primary heart tumour, outnumbering myxomas. However, there is no consensus about their aetiology. We investigated the molecular profile of these tumours using next generation sequencing in a cohort of 16 cases. Eleven of 14 (79%) analysable tumours showed mutations of the KRAS oncogene. Our results provide unambiguous evidence that a significant proportion of these lesions are genuine neoplastic tumours caused by an oncogenic driver mutation.

Clinical presentation and surgical results]

Papillary ibroelastomas are small benign intracardiac tumors known for their embolic potential. Since the introduction of echocardiography with improved resolution and transesophageal imaging techniques, they are being increasingly detected in clinical practice. In recent series, papillary fibroelastoma is considered the most frequent benign tumor of the heart. Our objective was to analyze characteristics and midterm surgical outcome of histologically-confirmed cases of papillary fibroelastoma. We conducted a retrospective study on patients with cardiac tumors submitted to surgical excision between June 1992 and February 2017. Out of 108 patients, 18 had papillary fibroelastomas. Their mean age was 58 years (22-77); 10 were men. The most frequent localizations were the aortic valve (7) and the mitral valve (5). None had significant valvular dysfunction. By transesophageal echocardiography, the tumor size (larger diameter) was 13.33 ± 5.55 mm (6.6-28.0). Two patients, both with tumor in the aortic valve, had suffered a stroke; other two had dyspnoea and atrial flutter, respectively. The remaining 14 patients were asymptomatic and their tumors were incidental findings. In 15 patients the valve was preserved. There was neither surgical mortality nor recurrence after 2.6 years of follow-up. In conclusion, most papillary fibroelastomas can be surgically removed with valve preservation and favorable clinical outcome. However, until the results of randomized trials support the decision, an aggressive surgical approach in asymptomatic patients needs to be defined in the context of surgical expertise.

Video-assisted endoscopic resection of left ventricular papillary fibroelastoma through the aortic valve

Papillary fibroelastoma is a rare, benign cardiac tumor. Surgical resection is indicated to prevent embolization. We herein report a case of a 78-year-old asymptomatic man who was found to have a mobile left ventricular papillary fibroelastoma anchoring deep in the left ventricle by incidental transthoracic echocardiography. The tumor was resected under visualization by a video-assisted rigid endoscope with a flexible head inserted through the aortic valve into the left ventricle. Intraoperative frozen section analysis provided a pathological diagnosis of papillary fibroelastoma. The postoperative course was uneventful. This technique is recommended for the observation and resection of a tumor anchoring deep in the left ventricle and is helpful for avoiding the adverse effects of left ventriculotomy.

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases

INTRODUCTION

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography.

OBJECTIVES

To describe the echocardiographic features of PFE and correlate them with the clinical presentation and initial treatment.

MATERIALS AND METHODS

A prospective analysis of patients with a diagnosis of PFE was conducted between 2000 and 2015. We assessed the clinical history, symptoms at the time of diagnosis, echocardiographic features, and initial treatment.

RESULTS

Fifty-four patients with a diagnosis of PFE by echocardiography were included. The incidence was 0.038%. Mean age was 62±16 years; 50% were male. Forty-six percent of patients had symptoms at the time of diagnosis, the most frequent of which was transient ischemic accident (TIA). Embolic episodes occurred in 31% of patients, mainly to the brain. PFEs were valvular in 70.4% of cases and multiple in 13%. Mean maximum length was 1.18±0.58 cm, and 44% were mobile. PFEs >1.5 cm were most often found in the heart valves (56.8% vs 10.8%; P=.045). There was no significant relation between size, mobility, location and number of tumors, and the presence of embolism or symptoms. Most frequent treatment was oral anticoagulation in 48.6%, followed by simple tumor resection in 42.8% of cases.

CONCLUSIONS

PFE is a small tumor, predominantly valvular and benign, but entails a high incidence of cerebral embolism. The initial approach should be individualized according to clinical manifestations, comorbidities, and the experience of the surgical center.

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.

Non-exophytic Lambl excrescences of aortic valves: a morphological study

AIMS

To elucidate the histopathological findings of classical Lambl excrescences (LEs) and non-exophytic LEs (non-ex LEs) without excrescent papillary features.

METHODS AND RESULTS

We examined 126 aortic valves (AVs) and revealed LEs (non-ex and/or classical), non-ex LEs and classical LEs in 106, 78 and 88 AVs, respectively. The detection of non-ex LEs was challenging, but elastica van Gieson stain highlighted their presence. Non-ex and classical LEs chiefly involved the ventricular regions, favoured posterior cusps and coexisted in the same areas of 31 AVs. A possible transformation of classical LEs into non-ex LEs was suggested histologically in 39 AVs. Non-ex LEs were associated with age of >70 years (P < 0.001) and marked deformity (P = 0.007). Classical LEs were associated inversely with marked deformity (P < 0.001), but not with age of >70 years. Compared with age- and sex-matched control AVs, non-ex LEs and marked deformity in dysfunctional AVs were more common (P = 0.037 and P < 0.001, respectively), but classical LEs were less common (P = 0.021).

CONCLUSIONS

Non-ex LEs have subtle features but are a common form of LEs, and seem to develop from classical LEs. AV dysfunction-related marked deformity can promote non-ex LEs.

A case of a fibroelastoma and patent foramen ovale in a patient with prior stroke

We describe the case of a patient who underwent patent foramen ovale (PFO) closure for secondary stroke prevention. On routine follow-up transesophageal echocardiography (TEE), a papillary fibroelastoma was identified and removed successfully surgically. The fibroelastoma had not been recognized during preprocedural imaging and escaped our attention during limited intraprocedural transesophageal echocardiographic imaging (focusing on the interatrial septum) given the small size and visualization requiring thorough imaging in multiple planes and modified views. Our case illustrates the importance of detailed echocardiographic imaging prior to PFO device implantation; otherwise, subtle concomitant and at least equally probable causes of stroke can be overlooked.

Papillary fibroelastoma of the pulmonary valve--a systematic review

The pulmonary valve is the least affected site for valvular papillary fibroelastoma. With increasing use of routine echocardiography and other modalities of imaging, pulmonary valve papillary fibroelastomas (PVPFE) are being recognized more frequently. PVPFE is more often an incidental diagnosis and symptomatic patients usually present with shortness of breath. Embolic phenomena and right ventricular outflow tract obstruction are the most serious complications of PVPFE. Since PVPFE is rare, the purpose of this systematic review is to address demographic characteristics, the clinical presentation, management, and outcome of this benign tumor of the pulmonary valve.

Multiple causes for an ischemic stroke: myxoma, papillary fibroelastomas and patent foramen ovale

We report a case in which multiple uncommon causes of an ischemic vascular accident coexisted in the same patient. The patient was admitted with signs of acute stroke. Investigation workup revealed a left atrial tumor (myxoma) and a patent foramen ovale. Intraoperatively, transesophageal echocardiography added new information: papillary fibroelastomas were found in the aortic valve. This finding dictated a change in the surgical plan, adding resection of aortic valve masses to the planned excision of the left atrial tumor and patent foramen ovale closure. The uniqueness of this case derives from the coexistence of rare primary cardiac tumors. There are only five cases in literature of myxoma concomitant with fibroelastoma and the occurrence of multiple fibroelastoma is also extremely rare. Moreover this case emphasizes the benefit of the intraoperative use of transesophageal echocardiography to improve the diagnosis and management of cardiac surgical patients.