AMA Category 1 Credit for Physicians Only.
ASRT CME is not available.
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The TEE showed:
TVAn 4.44 cm with mild TR
Mass of the Aortic Valve - Lambl's Excrescence versus Fibroelastoma
The mass is on the ventricular side of the RCC.
The differential diagnosis is:
Calcified Node of Arantii
Given the presentation, we felt that the tumor was a fibroelastoma (FBE) (also called a
papillary fibroelastoma (PFE). Fibroelastoma are benign cardiac tumors, accounting for 10% of all cardiac tumors, can occur on either side of the valve. FBE have been found on all valves. The aortic valve (48%) is more common than the mitral valve (37%). Male preponderance (58%) and the mean age is 56 years old.
FBE have been found as small as 2 mm and as large as 70 mm. Surgical excision occurred in 79% of cases. The origin of FBE is not known. FBE are not congenital, but, may have occurred in response to surgery, radiation, viral/inflammation, or is similar to a hamartoma. Some suthors believe FBE are neoplasms.
Fibroelastomas have similar appearance on cytology as do Lambl's Ecxrescences. FBE are consist of papillary fronds of collagen and elasting covered by endothelial cells. FBE are firmly attached to the valve. Embolism is thought to be unusual because fragments of FBEs have only rarely been found in arteries. It is more likely that FBE are a nidus for thrombus where the thrombus embolize rather than the FBE. Because of these reasons FBE may be treated with anticoagulation in whom surgery is contraindicated.
FBE can embolize or if large, cause obstructive events, such as myocardial infarction, CVA, TIA, sudden death when on the left side of the heart. If on the right side, pulmonary embolus can occur.
Ngaage et al did shave excision (83%), excision (9%), or valve replacement (6%) of aortic valve FBE. After
three years there was no tumor recurrence after three years.
If a patient has symptoms, surgery is indicated. However, what about asymptomatic patients?
Although guidelines are not present, one author felt that if the FBE is large (> 1cm) or mobile then increased risk demands that curative therapy be applied. However, left sided lesions that are small, immobile, and can be closely followed should be treated with anticoagulants until the FBE enlarges or symptoms occur.
[The lesion was very small and only on some of the loops. On the loops that it was present, it was only present in one of the cardiac cycles and not the other. Therefore, for such a small thing to be found could only have been found by a princess since only they can feel a pea under their mattress :)]
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Papillary fibroelastomas of the heart.
Fibroelastoma and embolic stroke
Sudden unexpected death due to papillary fibroma of the aortic valve: report of a case and review of the literature.
Fibroelastoma and Embolic Stroke
Echocardiographic Diagnosis of Aortic Valve Papillary Fibroelastoma
Surgical Treatment of Cardiac Papillary Fibroelastoma: A Single Center Experience With Eighty-Eight Patients
Asymptomatic papillary fibroelastoma of the Aortic valve in a young woman - a case report
Papillary fibroelastoma of the aortic valve - a case report and literature review