Transapical Left Ventricular Approach for Cardiac Papillary Fibroelastomas: A Case Report

Abstract

Background/aim: Cardiac papillary fibroelastomas (CPF) are benign tumors, frequently asymptomatic, characterized by a mobile pedunculated mass that arises from the endocardium. When CPF is located in the left ventricle, it may protrude into the left ventricular outflow tract and affect hemodynamics. They are highly thrombogenic, and can also cause some life-threatening events such as cerebral and peripheral embolization.

Case report: We herein report a case of a 74-year-old female admitted to our center with palpitations and dyspnea on exertion. Her past medical history revealed that she had had a transient ischemic attack 7 months before presentation. Echocardiography and cardiac magnetic resonance imaging revealed an intracardiac mass anchored in the anteroapical interventricular septum without interference with aortic or mitral valve functionality. Surgical resection of the left ventricular mass was performed through the left apical ventriculotomy approach. Histopathological examination of the tumor was suggestive of papillary fibroelastoma. The postoperative course was uneventful. The patient was discharged home on the eighth postoperative day, with no recurrence at 6 months.

Conclusion: Although left ventricular papillary fibroelastomas are benign tumors, they carry a high risk for embolic complications and therefore surgery should be proposed, the transapical approach being a safe and effective method.

Keywords: Cardiac papillary fibroelastomas; left ventricle; surgery.

Figure 1. A: Transthoracic echocardiography (apical four-chamber) showing a mobile, tumoral mass (arrow) in the left ventricle (LV) and a stalk attached to the anteroapical interventricular septum. B: Transthoracic echocardiography (long-axis view) showing no interference with mitral and aortic valves. Ao: Aorta; CPF: cardiac papillary fibroelastoma; LV: left ventricle; RV: right ventricle

Figure 2. Cardiac magnetic resonance imaging of the heart revealed a 1.5-cm pedunculated mass with intermediate signal intensity on T1- weighted images

Figure 3. Surgical view with an approach through the left apical ventricle, with cardiac papillary fibroelastoma adhered to the interventricular septum

Figure 4. Surgical view. The ventriculotomy was closed by double-layer running Prolene 4/0 stitches with underlying Teflon felt strips

Figure 5. On gross pathological examination, the cardiac papillary fibroelastoma was an ovoid, soft, gelatinous, white fragment of tissue (1.4×1.5 cm).

Figure 6. The histopathological findings showing multiple elongated and branching papillary fronds, consisting of an acellular matrix surrounded by a single layer of endothelial cells, led to the diagnosis of cardiac papillary fibroelastoma (hematoxylin and eosin staining, ×10).