CARDIOVASCULAR ANESTHESIA: Case Report
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.
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.
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.
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.
1. Morewood GH, Gallaher ME, Gaughan JP, Conlay LA. Current practice patterns for perioperative transesophageal echocardiography in the United States. Anesthesiology 2001; 95: 1507–12.
2. Michel-Cherqui M. Assessment of systematic use of intraoperative transesophageal echocardiography during cardiac surgery in adults: a prospective study of 203 patients. J Cardiothorac Vasc Anesth 2000; 14: 45–50.
3. Klarich KW, Enriquez-Sarano M, Gura GM, et al. Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathological correlation. J Am Coll Cardiol 1997; 30: 784–90.
4. Sun JP, Asher CR, Yang XS, et al. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. Circulation 2001; 103: 2687–93.
5. Edwards FH, Hale D, Cohen A, et al. Primary cardiac valve tumors. Ann Thorac Surg 1991; 52: 1127–31.
6. Shively BK. Transesophageal echocardiographic evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve. Cardiol Clin 2000; 18: 711–29.
7. Lee K, Topol EJ, Steward WJ. Atypical presentation of papillary fibroelastoma mimicking multiple vegetations in suspected subacute bacterial endocarditis. Am Heart J 1993; 125: 1443–5.
8. Grinda JM, Couetil JP, Chauvaud S, et al. Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolisation. J Thorac Cardiovasc Surg 1999; 117: 106–10.
9. Yee HC, Nwosu JE, Lii AD, et al. Echocardiographic features of papillary fibroelastoma and their consequences and management. Am J Cardiol 1997; 80: 811–4.
10. Sankar NM, Odayan MK, Morris M, et al. Cardiac valvular papillary fibroelastoma: a report of 2 cases. Tex Heart Inst J 1999; 26: 298–9.
11. Lopez-Sanchez E. Central retinal artery occlusion as the initial sign of aortic valve papillary fibroelastoma. Am J Ophthalmol 2001; 131: 667–9.
12. Giannessini C, Kubis N, Guyen AN, et al. Cardiac papillary fibroelastoma: a rare cause of ischemic stroke in the young. Cerebrovasc Dis 1999; 9: 45–9.
13. Topol EJ, Biern RO, Reitz BA. Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide to excision. Am J Med 1986; 80: 129–32.
14. Bossert T, Diegeler A, Spyrantis N, Mohr FW. Papillary fibroelastoma of the aortic valve with temporary occlusion of the left coronary ostium. J Heart Valve Dis 2000; 9: 842–3.
15. Grote J, Mugge A, Schfers HJ, et al. Multiplane transesophageal echocardiography detection of a papillary fibroelastoma of the aortic valve causing myocardial infarction. Eur Heart J 1995; 16: 426–9.
16. Thys DM. Echocardiography and anesthesiology successes and challenges: editorial views. Anesthesiology 2001; 95: 1313–4.
17. Ionescu AA, West RR, Proudman C, et al. Prospective study of routine perioperative echocardiography for elective valve replacement: clinical impact and cost-saving implications. J Am Soc Echocardiogr 2001; 14: 659–67.