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eComment: Cardiac papillary fibroelastoma: a current assessment

Department of Cardiothoracic Surgery, University Hospital of Patras, 22500 Rion Patras, Greece

Multiple papillary fibroelastoma in left ventricle associated with obstructive hypertrophic cardiomyopathy

Reading your interesting case report [1], several questions arise. It is notable that the patient was treated for three years with anticoagulants, while the left ventricle mass seems not to have been investigated during the above period. Particularly, symptomatic cardiac papillary fibroelastoma (CPF) should be surgically removed whereas asymptomatic lesions left-sided or >1 cm (as in your patient) should be considered for surgical excision according to the current literature [2]. The fact that you did not perform magnetic resonance imaging before the operation is also notable.

Generally, transesophageal echocardiography is the recommended method for diagnosis, with an overall sensitivity of 77% [2, 3]. Computed tomography is inferior to echocardiography in depicting small moving structures, such as on the cardiac valves, because it does not allow true real-time imaging. Magnetic resonance imaging is more valuable than computed tomography as it allows imaging in multiple planes and better soft-tissue characterization of the tumor. The main disadvantage of magnetic resonance imaging is its susceptibility to motion artefact [4]. Generally, cardiac catheterization and selective angiography are not necessary in most patients with CPF, as adequate information can usually be obtained by non-invasive imaging. Especially, cardiac catheterization appears warranted in cases where the other techniques have not fully defined the CPF or when another cardiac condition warranting cardiac catheterization is suspected. In contrast to non-invasive diagnostic techniques, cardiac catheterization can be associated with an added risk to patients because the catheter may dislodge a fragment of the tumor or adherent thrombi, resulting in embolism [3].

CPFs are generally slow growing tumors but may serve as a nidus, allowing formation of large superimposed thrombi over a short period of time. About 77% of CPFs originate on the valves, and the other 23% in the endocardial non-valvular surface, whereas >95% arise in the left heart [3]. Symptomatic CPFs should be surgically resected; the treatment of asymptomatic tumors is less clear. Large, left-sided mobile tumors should be excised to prevent sudden death and emboli. Small, non-mobile tumors may be followed with serial echocardiography and removed if they increase in size, or become mobile or symptomatic [2]. CPFs are usually pedunculated and may easily be removed with associated endocardial tissue. The root of the pedicle and the full thickness of endocardium involved are excised. Care should be taken to avoid fragmentation of the tumor to prevent embolization.

Various methods have been proposed for complete excision of left-sided CPFs to avoid a left ventriculotomy with its further complications. When a CPF is located on the aortic valve or on the left ventricular outflow tract, it is best approached via the transaortic route, and when located on the mitral valve, it is best approached via a left atriotomy [5]. For tumors deep within the left ventricular cavity close to the apex, the use of a cardioscope passing through the aortic or mitral valve is recommended to avoid damage to the valvular apparatus. Undoubtedly, surgery is curative with excellent short- and long-term prognosis after surgical removal. Moreover, recurrence after surgical resection has not been reported.

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1. Kobayashi Y, Saito S, Yamazaki K, Kurosawa H. Multiple papillary fibroelastoma in left ventricle associated with obstructive hypertrophic cardiomyopathy. Interact CardioVasc Thorac Surg 2009;9:921–923.[Abstract/Free Full Text]
2. Boodhwani M, Veinot JP, Hendry PJ. Surgical approach to cardiac papillary fibroelastomas. Can J Cardiol 2007;23:301–302.[Medline]
3. Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003;146:404–410.[CrossRef][Medline]
4. Grebenc ML, Rosado de Christenson ML, Burke AP, Green CE, Galvin JR. Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation. Radiographics 2000;20:1073–1103.[Abstract/Free Full Text]
5. Reuthebuch O, Roth M, Skwara W, Klövekorn WP, Bauer EP. Cardioscopy: potential applications and benefit in cardiac surgery. Eur J Cardiothorac Surg 1999;15:824–829.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Efstratios Apostolakis Nikolaos G. Baikoussis Permission Requests Google Scholar Articles by Koniari, I. Articles by Baikoussis, N. G. PubMed PubMed Citation Articles by Koniari, I. Articles by Baikoussis, N. G. Related Collections Related Article