ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Rafael Espada
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Espada, R.
Right arrow Articles by Verani, M. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Espada, R.
Right arrow Articles by Verani, M. S.

Ann Thorac Surg 1997;63:221-223
© 1997 The Society of Thoracic Surgeons

Case Report

Visualization of Ventricular Fibroelastoma With a Video-Assisted Thoracoscope

Rafael Espada, MD, Nirupama G. Talwalker, MD, George Wilcox, MD, Neal S. Kleiman, MD, Mario S. Verani, MD

Departments of Surgery, Cardiology, and Pathology, Baylor College of Medicine, The Methodist Hospital, Houston, Texas

Accepted for publication June 25, 1996.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Comment
 References
 
Left ventricular papillary fibroelastomas are associated with a high risk of cerebral embolization. Two-dimensional echocardiography and intraoperative transesophageal echocardiography are helpful in diagnosing tumors, planning a surgical approach, and achieving adequate excision. A video-assisted thoracoscope via the left atrium was used to visualize a left ventricular papillary fibroelastoma. Thoracoscopic visualization facilitated excision of a mass within the chordae tendineae between the anterolateral papillary muscle and the left ventricular wall. Video-assisted thoracoscopy greatly facilitates exposure/excision of deeper intracavitary left ventricular masses.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Comment
 References
 
Although papillary fibroelastomas are uncommon benign cardiac tumors, they are important because of their tendency to embolize [1, 2]. In recent years they have been diagnosed with increasing frequency by two-dimensional echocardiography. The left ventricle seems to be the least frequent site.

The purpose of this report is to highlight the role of the video-assisted thoracoscope, which greatly enhanced exposure of the intracavitary left ventricular tumor, making it accessible for complete surgical excision through the left atrium.

A 62 year-old male, insulin-dependent diabetic was admitted to a local hospital July 28, 1995, with sudden left hemiparesis and dysarthria. Computed axial tomographic brain scan revealed a low-density lesion in the right middle cerebral artery. Two-dimensional echocardiographic images (Fig 1Go) revealed a solitary, intracavitary, short-pedicled mass in the left ventricle just below the mitral valve. A left ventricular tumor was provisionally diagnosed. On August 8, 1995, the patient was transferred to The Methodist Hospital for further treatment.



View larger version (61K):
[in this window]
[in a new window]
  		Fig 1. . Two-dimensional echocardiogram showing tumor (arrows) in the left ventricular cavity. (Ao = aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.)

 
Cardiac catheterization revealed 90% obstruction of the left anterior descending coronary artery and 85% obstruction of the circumflex coronary artery requiring coronary artery bypass grafting. Preoperative transthoracic and intraoperative transesophageal echocardiograms showed a left ventricular formation and confirmed a solitary, mobile, rounded, homogenous, 3 x 2-cm intracavitary left ventricular mass with a short pedicle attached to the anteriolateral papillary muscle of the mitral valve. Magnetic resonance imaging was not considered necessary to complete this study. Under cardiopulmonary bypass, a left atriotomy was done and the mitral valve was evaluated. It appeared normal with no masses attached to the cusps. A video-assisted thoracoscope (Stryker 30-degree thoracoscope with three chip camera, Santa Clara, CA) was introduced through the mitral valve into the left ventricular cavity, greatly enhancing visualization of the subvalvular region and the interior of the cavity. A yellowish, soft, gelantinous, lobulated, fragile mass was located (Fig 2AGo) between the anterolateral papillary muscle and the left ventricular wall, enmeshed within the chordae tendineae. Under thoracoscopic visualization the mass was gently separated from the chordae and papillary muscle and completely removed (Fig 2BGo) in three pieces. Next, coronary artery bypass grafting was performed on the left anterior descending coronary artery using left internal mammary artery and to the first obtuse marginal coronary artery using a reversed segment of autogenous saphenous vein graft. Transesophageal echocardiography confirmed complete removal of the left ventricular mass. The postoperative course was uneventful. The patient was discharged on aspirin (1 per day orally) for anticoagulation.



View larger version (111K):
[in this window]
[in a new window]
  		Fig 2. . Interior of the left ventricle viewed through the video-assisted thoracoscope introduced via the left atrium showing (A) tumor attached to papillary muscle and (B) site of pedicle attachment seen after complete removal of tumor. (LV = left ventricle; M = cusps of mitral valve; P = papillary muscle; T = tumor.)

 
A 2.0 x 1.5-cm specimen of the excised tumor, sent for frozen-section histology, was reported as a nonvascular, benign myxomatous tissue. Histologic examination of the remaining pieces of specimen measuring 3.0 x 2.0 x 0.5 cm in aggregate definitively confirmed the diagnosis of papillary fibroelastoma.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Comment
References
 
Papillary fibroelastomas of the heart usually arise from the valvular endocardium, particularly of the aortic valve. Only 10% are nonvalvular [1, 3]. The absence of the classic sea anemone-like gross appearance, a nonvalvular intracavitary location in the left ventricle, and the large size of this tumor led to an initial, provisional diagnosis of myxoma. McAllister and Fenoglio [4] have described the typical histopathology of papillary fibroelastomas with overall structure of the fronds resembling that of chordae tendineae as in this case.

Surgical excision is curative [1, 2, 5–8] and indicated even in asymptomatic patients to prevent catastrophic embolic complications. Mitral valve and aortic valve replacements have been used for fibroelastomas involving these valves [2, 8].

This mass would have been very difficult to visualize and dissect from its deep attachments to the left ventricular wall, chordae tendineae, and papillary muscle of the mitral valve through left atriotomy alone. The thoracoscope facilitated visualization and removal of the mass in toto. The usefulness of intraoperative transesophageal echocardiography in localizing a benign cardiac tumor and assessing adequacy of excision has been noted previously [2, 7, 8].

This case also emphasizes the propensity of cardiac papillary fibroelastomas for cerebral embolism. A high index of suspicion is necessary for clinical diagnosis, which can be confirmed by two-dimensional echocardiography. Complete surgical excision of this benign tumor is curative and achievable with the help of transesophageal echocardiography and video-assisted thoracoscopy. Intracavitary left ventricular tumors that are deeply situated, poorly visualized, and inaccessible via left atriotomy alone may be made accessible with the thoracoscope-aided, left atrial approach. Tumors in the left ventricular outflow tract with aortic valve involvement require a transaortic approach. The transthoracic approach should also be considered to inspect the left ventricle. Video-assisted thoracoscopy-aided atriotomy also may be helpful in surgical management of other intracardiac masses including thrombi.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Comment
 References
 
Address reprint requests to Dr Espada, Department of Surgery, Baylor College of Medicine, 6535 Fannin, #A886, Houston, TX 77030.


   References
Top
 Footnotes
 Abstract
 Introduction
 Comment
 References
 

  1. Edwards FH, Hale D, Cohen A, Thomson L, Pezzella T, Virmani R. Primary cardiac valve tumors. Ann Thorac Surg 1991;52:1127–31.[Abstract/Free Full Text]
  2. Schwinder ME, Katz E, Rotterdam H, Slater J, Weiss EC, Kronzon I. Right atrial papillary fibroelastoma: diagnosis by transthoracic and transesophageal echocardiography and percutaneous transvenous biopsy. Am Heart J 1989;118:1047–50.[Medline]
  3. Flotte T, Pinar H, Feiner H. Papillary elastofibroma of the left ventricular septum. Am J Surg Pathol 1980;4:585–8.[Medline]
  4. McAllister HA, Fenoglio JJ Jr. Tumors of the cardiovascular system. In: Atlas of tumor pathology. Second series, fascicle 15. Washington, DC: Armed Forces Institute of Pathology, 1978.
  5. Shub C, Tajik AJ, Seward JB, et al. Cardiac papillary fibroelastomas. Two-dimensional echocardiographic recognition. Mayo Clin Proc 1981;56:629–33.[Medline]
  6. Almargo UA, Perry LS, Choi H, Pinar K. Papillary fibroelastoma of the heart. Arch Pathol Lab Med 1982;106:318–21.[Medline]
  7. Topol EJ, Biern RO, Reitz BA. Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide to excision. Am J Med 1986;80:129–32.[Medline]
  8. De Viriglio C, Dubrow TJ, Robertson JM, et al. Detection of multiple cardiac papillary fibroelastomas using transesophageal echocardiography. Ann Thorac Surg 1989;48:119–21.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 BMJ Case ReportsHome page
P. K. Mishra, P. Davison, S. Lakshmanan, G. Martinelli, and S. J. Billing
Ventricular mass: a clinical and surgical conundrum
BMJ Case Reports, August 11, 2011; 2011(aug11_1): bcr0420102875 - bcr0420102875.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
A. Iribarne, R. Easterwood, M. J. Russo, J. Yang, F. H. Cheema, C. R. Smith, and M. Argenziano
Long-Term Outcomes With a Minimally Invasive Approach for Resection of Cardiac Masses
Ann. Thorac. Surg., October 1, 2010; 90(4): 1251 - 1255.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
O. A. Araji, M. A. Gutierrez-Martin, N. Miranda, and J. M. Barquero
Video-assisted cardioscopy for removal of primary left ventricular fibroma
Interact CardioVasc Thorac Surg, February 1, 2010; 10(2): 344 - 345.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. Le Guyader and M. Laskar
Removal of left ventricular tumors by a transaortic transvalvular approach with the help of thoracoscopic instruments.
J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 537 - 538.
[Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
H. G. Je, Y. S. Kim, S.-H. Jung, and J. W. Lee
Resection of left ventricular papillary fibroelastoma through thoracoscopic-assisted minithoracotomy
Interact CardioVasc Thorac Surg, April 1, 2008; 7(2): 320 - 321.
[Abstract] [Full Text] [PDF]

Home page
 Card Surg AdultHome page
J.-C. M. Walkes, W. R. Smythe, and M. J. Reardon
Cardiac Neoplasms
Card. Surg. Adult, January 1, 2008; 3(2008): 1479 - 1510.
[Full Text]

Home page
 Interact CardioVasc Thorac SurgHome page
A. Le Guyader, K. Nubret, N. Darodes, and M. Laskar
Removal of a ventricular mitral valve fibroelastoma by an aortic approach
Interact CardioVasc Thorac Surg, December 1, 2006; 5(6): 785 - 787.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
Y. Kaneko, J. Kobayashi, F. Saitoh, and M. Ono
Thoracoscopic removal of a papillary fibroelastoma in the left ventricular apex
Interact CardioVasc Thorac Surg, October 1, 2006; 5(5): 640 - 642.
[Abstract] [Full Text] [PDF]

Home page
 Interact CardioVasc Thorac SurgHome page
T. Bossert, J. F. Gummert, R. Battellini, M. Richter, M. Barten, T. Walther, V. Falk, and F. W. Mohr
Surgical experience with 77 primary cardiac tumors
Interact CardioVasc Thorac Surg, August 1, 2005; 4(4): 311 - 315.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. Tsukube, M. Okada, Y. Ootaki, Y. Tsuji, and C. Yamashita
Transaortic video-assisted removal of a left ventricular thrombus
Ann. Thorac. Surg., September 1, 1999; 68(3): 1063 - 1065.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
N. G. Talwalkar, J. J. Livesay, B. Treistman, and C. E. Lacle
Mobilization of the anterior mitral leaflet for excision of a left ventricular myxoma
Ann. Thorac. Surg., May 1, 1999; 67(5): 1476 - 1478.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J.-M. Grinda, J. P. Couetil, S. Chauvaud, N. D'Attellis, A. Berrebi, J.-N. Fabiani, A. Deloche, and A. Carpentier
CARDIAC VALVE PAPILLARY FIBROELASTOMA: SURGICAL EXCISION FOR REVEALED OR POTENTIAL EMBOLIZATION
J. Thorac. Cardiovasc. Surg., January 1, 1999; 117(1): 106 - 110.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. D. Goldin, K. B. Allen, R. Mitra, and R. Espada
Papillary Fibroelastoma
Ann. Thorac. Surg., October 1, 1997; 64(4): 1226 - 1226.
[Full Text]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Rafael Espada
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Espada, R.
Right arrow Articles by Verani, M. S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Espada, R.
Right arrow Articles by Verani, M. S.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS