Ann Thorac Surg 2009;87:928-930. doi:10.1016/j.athoracsur.2008.07.044
© 2009 The Society of Thoracic Surgeons
Case Reports
Papillary Fibroelastoma in the Left Ventricle Resected Under the Guidance of a Gastrointestinal Fiberscope
Masafumi Akita, MD, PhDa,*,
Hiroshi Ando, MD, PhDb,
Yoji Iida, MD, PhDc
a Department of Cardiovascular Surgery, Kasukabe Chuo General Hospital, Kasukabe City, Saitama, Japan
b Department of Cardiology, Kasukabe Chuo General Hospital, Kasukabe City, Saitama, Japan
c Department of Cardiology, Kobari General Hospital, Noda City, Chiba, Japan
Accepted for publication July 11, 2008.
* Address correspondence to Dr Akita, Department of Cardiovascular Surgery, Kasukabe Chuo General Hospital, 5-9-4 Midori cho, Kasukabe City, Saitama, 344-0063, Japan (Email: markun{at}estate.ocn.ne.jp).
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Abstract
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We report the case of a left ventricular mass in a 72-year-old man with ischemic heart disease. The tumor was deep in the left ventricle, and we considered that it would be difficult to directly visualize. Therefore, we inserted a gastrointestinal fiberscope into the heart. The tumor that was detected appeared to be a papillary fibroelastoma that arose from the left ventricular anterior papillary muscle. We resected the tumor under the guidance of a gastrointestinal fiberscope and performed coronary artery bypass grafting. The gastrointestinal fiberscope was useful for observing and resecting the deep left ventricular tumor.
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Introduction
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Primary cardiac neoplasm is a rare and papillary fibroelastoma that accounts for 8% of benign tumors. In this report, we present a case of papillary fibroelastoma that arose from the left ventricular anterior papillary muscle, which was resected under the guidance of a gastrointestinal fiberscope.
A 72-year-old man complained of chest compression. A left ventricular tumor had been indicated by echocardiography, which was performed at another hospital 2 years previously; however, it had been left untreated. Cardiac catheterization showed three-vessel disease and no tumor-feeding artery was observed.
Echocardiography revealed a highly echoic, movable mass that was connected to the left ventricular anterior papillary muscle (Fig 1). Because the cardiac wall motion was normal, and there was no tumor-feeding artery, and because of the tumor location, thrombus was ruled out, and myxoma or papillary fibroelastoma was suspected. We planned to carry out tumor resection and coronary artery bypass grafting. Cardiopulmonary bypass was established in a standard manner, and the aorta was cross-clamped. We made right atrial and atrial septal incisions, and we proceeded to the left ventricle through the atrial septum because we wanted to observe the tumor directly from the transseptal incision. However, we were unable to observe the tumor because it appeared to be attached deep to the left ventricular anterior papillary muscle. Therefore, we used a gastrointestinal fiberscope to observe the entire tumor and resect it under fiberscopic guidance (Fig 2). After removal of the tumor, we performed coronary artery bypass grafting.
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Fig 1. Echocardiogram shows a highly, echoic movable mass (14.3 x 12.3 mm) in the left ventricle attached to the anterior papillary muscle.
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The resected tumor was 
15 mm in size and in water, and it had the appearance of a sea anemone (Fig 3). The tumor was pathologically diagnosed as papillary fibroelastoma.
The postoperative course was uneventful. The patient was followed for 3 years with no recurrence being observed.
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Comment
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Primary cardiac neoplasms are rare and are detected in 0.001% to 0.03% of all necropsy cases. Among primary cardiac neoplasms, benign tumors account for 63% and malignant tumors for 37%. Papillary fibroelastoma accounts for 8% of all primary cardiac neoplasms. Papillary fibroelastoma often occurs near the valves (81%). Only approximately 1% of cases arise from the left ventricular papillary muscle [1].
Papillary fibroelastoma is said to be a benign, avascular, endocardial papilloma that is associated with Lambl excrescence. It is suggested that shear stress and congenital factors may be involved in its development but the cause is still unclear. It occurs almost equally in men and women, and it frequently occurs in persons in their 60s and occasionally in teenagers. It is macroscopically characterized by the appearance of a sea anemone in water. Symptoms include cerebral infarction and transient cerebral ischemic attack associated with soft and fragile fibroelastoma in 44% of patients, angina pectoris in 18%, myocardial infarction in 10%, cardiac failure in 9%, and sudden death in 8% [2]. Simple resection is accepted as a general treatment. Recurrence after surgical resection had not been reported, but Tanaka and colleagues [3] have reported multiple, double primary papillary fibroelastoma.
There are various approaches for treating the tumor in the left ventricle, but because papillary fibroelastoma can be treated with simple resection, a less invasive method with good visualization would be the best approach. Borsani and colleagues [4] resected papillary fibroelastoma that adhered to the chordae of the anterior mitral valve leaflet by a left paraseptal access. Sato and colleagues [5] resected papillary fibroelastoma from the aorta by an aortotomy. Matsuo and colleagues [6] resected papillary fibroelastoma by inserting a fiberscope from the incision site of the aorta. In the present case, the tumor was attached to the deep anterior papillary muscle. It was difficult to visualize the tumor; therefore, we made right atrial and atrial septal incisions to approach the tumor, rather than using right-sided, left atrial and aortic incisions. In addition, the tumor was adjacent to the anterior papillary muscle; we considered it would be impossible to see in the left ventricular, inner anterior wall by thoracoscopy with a straight shaft. To avoid such disadvantages as inflexibility and poor handling of the thoracoscope, we used a gastrointestinal fiberscope.
The advantages of a gastrointestinal fiberscope are its flexibility, which enables the ability to look inside the left ventricle from all angles with good visualization, even for adjacent tumors, and to wash off the blood on the lens with water. In addition, we can observe the tumor by grasping it with wires and obtain a biopsy.
In this report, we presented a case of papillary fibroelastoma attached to the left ventricular anterior papillary muscle. Due to poor visualization in the left ventricle, we resected the tumor using a gastrointestinal fiberscope. This device was very useful in observing and resecting the tumor in the left ventricle.
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References
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- Burke A, Virmani R. Tumors of the heart and great vessels Atlas of tumor pathology, 3rd series, Fascicle 16. Washington, DC: Armed Forces Institute of Pathology; 1996. pp. 1-54.
- Gowda RM, Khan IA, Nair CK, et al. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases Am Heart J 2003;146:404-410.[Medline]
- Tanaka H, Narisawa T, Mori T, Masuda Y, Kishi D. Double primary left ventricular and aortic valve papillary fibroelastoma Circ J 2004;68:504-506.[Medline]
- Borsani P, Mariscalco G, Blanzola C, et al. Asymptomatic cardiac papillary fibroelastoma: diagnostic assessment and therapy J Cardiac Surg 2006;21:77-80.[Medline]
- Sato Y, Yokoyama H, Satokawa H, Takase S, Maruyama Y. A report of a surgical case of papillary fibroelastoma in the left ventricular outflow tract Ann Thorac Cardiovasc Surg 2003;9:270-273.[Medline]
- Matsuo Y, Hanayama N, Hirasawa Y, Kawashima D. Excision of a cardiac papillary fibroelastoma with the use of a fiberscope J Cardiac Surg 2007;22:54-55.[Medline]
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Abstract
Introduction
