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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Only a princess can find this one.
Case#: 50
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
65 yo male with a history of an embolic CVA.

Please review the echo loops and consider the following questions?

What is the etiology of his CVA?
What is the differential diagnosis?
What are the recommendations for this diagnosis for a patient without a TIA or CVA?
What are the recommendations for this diagnosis for a patient with a history of a TIA or CVA?
What is your recommendation for this case?
How long after a CVA should you wait to decrease the risk of another CVA?


Case Discussion/CME Questions
The TEE showed:

TVAn 4.44 cm with mild TR

Mild MR
Mass of the Aortic Valve - Lambl's Excrescence versus Fibroelastoma
The mass is on the ventricular side of the RCC.

The differential diagnosis is:

Lambl's Ecxrescences
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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