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Aortic Valve Fibroelastomas as an Incidental Intraoperative Transesophageal Echocardiographic Finding

Gologorsky, Edward, MD; Gologorsky, Angela, MD

doi: 10.1097/00000539-200211000-00015
CARDIOVASCULAR ANESTHESIA: Case Report
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Department of Anesthesiology, Memorial Regional Hospital, Hollywood, Florida

Supplemental material available at http://www.anesthesia-analgesia.org.

June 17, 2002.

Address correspondence to Edward Gologorsky, MD, Anesthesia Department, Memorial Regional Hospital, 3501 Johnson St., Hollywood, FL 33021. Address e-mail to IntMedCo@aol.com.

Transesophageal echocardiography (TEE) is widely used by anesthesiologists for perioperative monitoring (1). Its use was reported to significantly affect the intraoperative surgical decision making in select groups of patients (2). We present two cases (both within the last year) where intraoperative TEE resulted in the incidental finding of aortic valve (AV) fibroelastomas.

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Case Reports

Case 1

A 35-yr-old otherwise healthy woman presented for mitral valve replacement as a component of treatment for idiopathic hypertrophic subaortic stenosis. Preoperative transthoracic 2D echocardiography and TEE examinations indicated left ventricular (LV) outflow obstruction, septal hypertrophy, anterior systolic movement of mitral valve, pulmonary hypertension, and a pressure gradient across the LV outflow tract of 23 mm Hg, increasing to 130 mm Hg with exercise. AV structure seemed to be normal. Intraoperative TEE examination by an anesthesiologist confirmed these data but also revealed a small pedunculated mass, sized approximately 5 mm in diameter, attached to the right coronary cusp of the AV. A fibroelastoma of the AV was suspected, and the surgical procedure was modified to include a valve-sparing resection of that mass. Postoperative pathological examination confirmed the diagnosis of a papillary fibroelastoma.

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Case 2

A 69-yr-old man with a history of severe coronary artery disease, multiple previous myocardial infarctions, and severely impaired LV function (estimated ejection fraction of 20%) presented for coronary artery re-vascularization. An intraoperative TEE examination by the anesthesiologist confirmed the preoperative catheterization finding of a dilated, globally hypocontractile LV. A small pedunculated mass, approximately 6 mm in diameter, was found attached to the right cusp of the AV (Fig. 1A–C). Once again, a fibroelastoma was suspected, and a valve-sparing resection of the AV mass was performed in addition to the planned coronary bypass surgery. Postoperative pathological examination confirmed the diagnosis of a papillary fibroelastoma.

Figure 1

Figure 1

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Discussion

Papillary fibroelastomas are rare benign cardiac tumors arising from the normal endocardial components (3). They are avascular, usually small, and are attached to valvular structures. They are observed on both right and left sides of the heart, most often on the AV apparatus (more on the aortic than ventricular side), and less frequently at the mitral location. Even though the aortic location affords a possibility for dynamic coronary ostial obstruction and embolism, most of these lesions are clinically silent and are reported as an incidental surgical or autopsy finding (4,5). Echocardiographically, they present as highly mobile excrescences, variable in size (up to 4 cm in diameter) and number (up to eight), attached to the endocardium by a stalk, characterized by connective tissue reflectance, occasionally containing some echo-lucent areas within the tumor (3–6), and even masquerading as vegetations (6,7).

Detection of papillary fibroelastomas carries important therapeutic implications. In patients scheduled for cardiac surgery, the intraoperative removal of left-sided lesions is often advocated because of attendant risks of systemic or intracerebral embolization, sudden death, and coronary occlusion (8–15). The typically benign nature of papillary fibroelastomas and the small risk of recurrence may favor a conservative valve-sparing technique (4,8–10).

The intraoperative use of TEE by anesthesiologists was reported to provide new data in 12.8%–38.6% of patients with cardiac pathology and often prompting changes in perioperative management (16). In the first presented case, both preoperative transthoracic 2D echocardiography and TEE did not identify the lesion. Various explanations were offered for the failure to echographically diagnose the fibroelastoma before surgery, including technical difficulties and small index of suspicion for rare pathology (4). In contrast, an intraoperative TEE performed by a skilled physician may afford better delineation of pathology, allowing a deliberate, careful examination and optimal high-resolution imaging. Even though intraoperative TEE was found to be cost-effective only in a small proportion of the cardiac surgery patients (17), it is now widely used in most tertiary care centers. In the presented cases, the routine use of an intraoperative TEE for all cardiac surgical procedures led to the incidental discovery and treatment of a rare, but potentially devastating, pathology.

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