Asian Cardiovasc Thorac Ann 2001;9:71-72
© 2001 Asia Publishing EXchange Pte Ltd
Transaortic Excision of Left Ventricular Papillary Fibroelastoma
Suhas C Bendre, MD,
Alec Baker, PA-C,
Todd M Grehl, MD
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Division of Cardiovascular Surgery Good Samaritan Hospital Corvallis, Oregon, USA
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For reprint information contact: Todd M Grehl, MD Tel: 1 541 766 3662 Fax: 1 541 757 5014 email: tmg{at}goodsam.com Division of Cardiovascular Surgery, Good Samaritan Hospital, 3600 N.W. Samaritan Drive, Suite 3116, Corvallis, OR 97330, USA.
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Abstract
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Transthoracic echocardiography in a 75-year-old woman with fatigue, dizziness, and left-sided weakness, demonstrated a 3.5 x 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.
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Introduction
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Papillary fibroelastoma is a rare benign neoplasm with a frequency of 0.002% to 0.33%, comprising 7.9% of benign primary cardiac tumors.1,2 It is the third most frequent benign tumor of the heart, after myxoma and lipoma. It typically affects the cardiac valves, mainly the aortic and mitral valves, and very rarely the endocardium. It may present with serious complications such as a cerebro-vascular event, myocardial ischemia or infarction, or pulmonary embolism.
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Case Report
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A 75-year-old woman was admitted with increasing fatigue, dizziness, and left-sided weakness associated with difficulty in walking. She had no history of neurologic events or cardiac disease. Neurologic evaluation by carotid Doppler ultrasound revealed minimal bilateral intimal thickening of the common carotid arteries. A computed tomography scan of the head showed no evidence of infarction or a space-occupying lesion. Transthoracic echocardiography demonstrated a 3.5 x 3-cm mobile but broad-based mass firmly attached to the anterior apical segment and septal portion of the left ventricle near the apex (Figure 1
). The mass was not associated with the papillary muscles or chordae of the mitral valve. The mitral valve appeared anatomically and functionally normal. There was no other cardiac valvular or cavitary pathology on echocardiography. Ventricular function was normal. Although the neurologic symptoms cleared quickly, they were assumed to be due to embolic material emanating from the left ventricular mass, thus the patient was referred for surgical intervention. She underwent coronary angiography before surgery, which revealed normal coronary arteries. Excision of the mass was carried out under cardiopulmonary bypass using standard techniques. The ascending aorta was opened in an oblique fashion with the incision carried down into the non-coronary sinus. The aortic valve leaflets were retracted carefully and the mass was excised by sharp dissection. Further inspection of the left ventricular chamber after resection of the mass revealed the papillary muscles and chordae to be intact. The patient was weaned from bypass without difficulty. Postoperative recovery was uneventful. Histology confirmed the mass was a papillary fibroelastoma.
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Discussion
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These tumors are never present at birth.3 The etiology remains elusive but their incidence increases with age. The youngest patient reported was a 3.5-year-old boy who presented with a stroke.4 Most of these tumors remain silent and are detected incidentally at surgery or autopsy. At least 10 cases of left ventricular fibroelastoma treated by surgical excision have been reported in the literature.5 Cardiac papillary fibroelastoma can present as solitary or multiple intracavitary tumors.6,7 Although benign, it may cause devastating complications such as coronary or cerebral emboli. Embolization may occur from the fragile papillary fronds of the tumor itself or from a thrombus forming on the tumor. The exact cause of the neurologic symptoms in our patient was difficult to ascertain. Histological examination of the excised tumor showed elastic fibers, fibrous tissue, and collagen fibers with an outer layer consisting of regular endothelial cells.
Various methods have been proposed for complete excision of a left ventricular tumor. It is most important to avoid a left ventriculotomy with its subsequent complications such as bleeding and myocardial fibrosis. This leaves only 2 modes of access to a left ventricular tumor: transaortic and trans-left atrial. Papillary fibroelastoma commonly arises from the valvular endocardium. When associated with the mitral valve, it is best approached via a left atriotomy. When associated with the aortic valve and left ventricular outflow tract, it is best approached via the transaortic route. When the tumor is close to the apex deep within the left ventricular cavity, different techniques have been described, particularly the use of a videoscope passing through the aortic or mitral valve to avoid damage to the valvular apparatus and to achieve complete surgical excision. Along with this technique, transthoracic and intraoperative transesophageal echocardiography can help in making surgical decisions. In our patient, there was an isolated tumor of reasonable size, which we were able to visualize completely and thus could excise through the aorta.
Even though it is histologically benign and clinically asymptomatic, cardiac papillary fibroelastoma should be excised because of the potential embolic complications. The diagnosis of this tumor should be considered in patients with unexplained cardiovascular or cerebro-vascular ischemia.
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Acknowledgments
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We are grateful to Cindy Fessler for her help in the preparation of the manuscript.
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References
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Bailbe M, Coisne D, Babin P, Corbi P, Menu P, Rosier MP, et al. Papillary fibroelastoma. A rare etiology of strokes in young patients [French]. Rev Med Interne 1998;19: 119–22.[Medline]
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de Virgilio C, Dubrow TJ, Robertson JM, Siegel S, Ginzton L, Nussmeier M, et al. Detection of multiple cardiac papillary fibroelastomas using transesophageal echocardiography. Ann Thorac Surg 1989;48:119–21.[Abstract]
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Abstract
Introduction
