Anesth Analg 2007;104:504-505
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000255899.96263.8a
CARDIOVASCULAR ANESTHESIA
Papillary Fibroelastoma of the Root of the Left Atrial Appendage Found Incidentally by Transesophageal Echocardiography During Cardiac Surgery
Noriko Shimode, MD*,
Sachiko Yada, MD*,
Yukari Okano, MD*,
Chikara Tashiro, MD*,
Toshihiro Ohata, MD
, and
Yuji Miyamoto, MD
From the Departments of *Anesthesiology and Cardiovascular surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
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Introduction
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A 76-year-old man was scheduled for coronary artery bypass graft surgery and mitral annuloplasty using cardiopulmonary bypass. His medical history included a right subarachnoid hemorrhage, angina pectoris, myocardial infarction 23 yr earlier, and percutaneous coronary intervention. Because of progressive dyspnea, he underwent cardiac catheterization that revealed severe three-vessel coronary artery disease. Preoperative transthoracic echocardiography revealed severe hypokinesis of the inferior and posterior left ventricular walls and Grade III mitral valve incompetence, but no other abnormality. After induction of general anesthesia, transesophageal echocardiography examination revealed a 10 x 7 mm mass arising from the root of the left atrial appendage in the midesophageal aortic valve short axis view and left atrium (LA) appendage views (Figs. 1 and 2, please see video loop available at www.anesthesia-analgesia.org). The mass was mobile and arose from a 1- to 5-mm pedicle. Examination of the mass at the time of surgery confirmed the attachment of a peduculated mass to the LA wall between the LA appendage and mitral valve annulus. Macroscopic examination demonstrated a white, smooth appearance with a long stalk, but without surrounding thrombus. Histological examination showed multiple branching papillary fronds consisting of dense fibroelastic tissue surrounded by a layer of loose connective tissue consistent with the diagnosis of cardiac papillary fibroelastoma (CPF).
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Figure 1. Midesophageal AV short axis view shows cardiac papillary fibroelastoma in the LA. The arrow shows cardiac papillary fibroelastoma. LA, left atrium; RA, right atrium; AV, aortic valve.
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Figure 2. LA appendage view. The arrow shows cardiac papillary fibroelastoma under Warfarin ridge. LA, left atrium.
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Primary cardiac tumors are very rare, with a frequency of approximately 0.02%. CPF is the third most common primary benign cardiac tumor after myxoma and lipoma (1). Most patients with CPF do not present with cardiac symptoms; rather, CPF is identified at autopsy or incidentally during cardiac surgery. The most common clinical symptoms are due to systemic embolization resulting in transient ischemic attack or stroke (2). In a large series (n = 611 patients), the most common location of CPF was aortic valve (n = 223 patients). Rarely, CPF was found in the LA (n = 10 patients), LA appendage (n = 2 patients), and the Eustachian valve (n = 2 patients) (2). As in our case, others have found transesophageal echocardiography to be more sensitive than transthoracic echocardiography for detecting CPF (3). The discordant diagnostic sensitivity was attributed to varying size, location, and diameter of CPF (3).
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ACKNOWLEDGMENTS
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The authors acknowledge the assistance of Dr. Hiroyuki Hao, Department of Surgical Pathology, Hyogo College of Medicine, Hyogo, 663-8501, Japan with the preparation of this paper.
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Footnotes
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Accepted for publication November 9, 2006.
Address for correspondence and reprint requests to Noriko Shimode, MD, Department of Anesthesiology, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan. Address e-mail to nshimode{at}hyo-med.ac.jp.
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
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REFERENCES
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- Kurup AN, Tazelaar HD, Edwards WD, et al. Iatrogenic cardiac papillary fibroelastoma: a study of 12 cases (1990–2000). Hum Pathol 2002;33:1165–9.[ISI][Medline]
- Gowda RM, Khan IA, Nair CK, et al. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003;146:404–10.[ISI][Medline]
- Baba Y, Tsuboi Y, Sakiyama K, et al. Cardiac papillary fibroelastoma as a cause of recurrent ischemic strokes: the diagnostic value of serial transesophageal echocardiography. Cerebrovasc Dis 2002;14:256–9.[ISI][Medline]
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