the Mitral Valve - Europe PMC

0 downloads 0 Views 1MB Size Report
We report a case of myocardial infarction secondary to coronary embolization of a papillary fibroelastoma of the anterior mitral leaflet. The patient underwent ...
Case

Reports

Alessandro Mazzucco, MD Giuseppe Faggian, MD Uberto Bortolotti, MD Raffaele Bonato, MD Demetrio Pittarello, MD Giuseppe Centonze, MD Gaetano Thiene, MD

Embolizing Papillary Fibroelastoma of the Mitral Valve We report a case of myocardial infarction secondary to coronary embolization of a papillary fibroelastoma of the anterior mitral leaflet. The patient underwent successful operation. The English literature describes only 9 other surgically excised papillary fibroelastomas of the mitral valve. In 5 of these cases, the patient presented with signs of cerebral or coronary embolization. Our case further confirms that intracardiac papillary fibroelastomas pose a major threat of systemic embolization and that the clinician should be alert to the possibility of this condition, particularly in young patients who present with myocardial infarction or other conditions that could have arisen from systemic embolization. (Texas Heart Institute Journal 1991;18:62-6)

Ppapillary fibroelastomas

are rare,

benign intracardiac

tumors

that, in the

past, have usually been incidental findings at surgery or necropsy.'-3 These tumors are of extreme clinical importance, however, because of their strong tendency to embolize.4 So far, the English literature has contained only 9 reports (Table I) of surgically excised papillary fibroelastoma of the mitral

valve.4-'2 We describe an additional case, in which tumor led to an acute myocardial infarction.

coronary

embolization of the

Case Report

Key words: Cardiac neoplasms; echocardiography; embolism; fibroma; mitral valve; myocardial infarction; papilloma From: The Departments of Cardiovascular Surgery (Drs. Mazzucco, Faggian, and Bortolotti), Anesthesiology (Drs. Bonato and Pittarello), and Pathology (Dr. Thiene), University of Padua Medical School, Padua, Italy; and Cardiology Service (Dr. Centonze), Civic Hospital, Matera, Italy Address for reprints: A. Mazzucco, MD, Istituto di Chirurgia

Cardiovascolare, Universita di Padova, Via Giustiniani 2, 35128 Padua, Italy

62

In March of 1989, a 25-year-old man was hospitalized for constrictive chest pain, which had developed suddenly while he was playing soccer. Electrocardiography showed evidence of an acute anterior myocardial infarction, which was treated with intravenous streptokinase and heparin. A 2-dimensional echocardiogram showed an area of apical akinesia, as well as a small mass on the anterior mitral leaflet, which was interpreted as a vegetation. In May of 1989, after the acute phase of the myocardial infarction had been resolved, the patient was transferred to our hospital for further evaluation. On admission, he was asymptomatic, with a blood pressure of 120/80 mmHg and a pulse rate of 85 beats/min. Physical findings were unremarkable. The chest roentgenogram was normal, and the electrocardiogram showed sinus rhythm with signs of anterior necrosis. Cardiac catheterization and angiography indicated mildly depressed left ventricular contractility with an ejection fraction of 66%; akinetic areas were noted at the apex of the left ventricle and in the anterior portion of the interventricular septum, but the coronary arteries were normal. Neither the intracardiac mass nor the embolus was detectable at angiocardiography. Repeat transthoracic 2-dimensional echocardiography, however, showed an isolated round mass that measured approximately 1 cm and was firmly attached to the anterior mitral leaflet. The anatomy of the mitral valve was normal. Because of the similarity between this case and another one that we had recently treated,'3 and because of the lack of any clinical sign of infection, the mass was suspected to be an intracardiac papilloma, which had caused the myocardial infarction through release of an embolus directly into the coronary circulation. In light of this diagnosis, the patient was scheduled for emergency surgery. After anesthesia had been induced, a transesophageal 2-dimensional echocardiographic probe was inserted to enable better visualization of the tumor and its site of attachment. This method confirmed the tumor's intimate relationship with

Mitral Valve Papillary Fibroelastoma

Volume 18, Number 1, 1991

0D

C

c 0

LL

a

E

OCO

c

0

°E°

0

c:D

0

c

c

E

UJ uJ

0

LLI

ET D

-6

C

0

.

0

0o

.0

L-

00

c

co

E ooC

0

Co

c

ND

0

L-

0 0

0

co

o

o

~0co -

So

0

to

-0

-0 a) E

0 * X,.2 0.0

E

E

Cu

Cu

cu

0

0

tf 0)

-i

f

E

cu

mC-,

c

+

0f-


>

c-

cn E fin ~~~~~~~~~~~~ ~~~E ~

> $

CL

Cu

c

C

C

0

0

0

0 0

cn

tn *4:

n

-:n

cf 0

c

uzn *-

*C.)i x LU

x

LlJ

*5 x

x

LL

LL

*C)> X co LL >

c

C

C

0 0

0

cn ua

cn

'a

> c

a

LU >

LU

X

0

C 0

0

cn

An

cn

a

a

a

X

x

x

x

LU

LU

U)

U)

'u

E E 0)

0

0 -0 -C

C

u

coc o) o.

LU

O

C

0o

OL cc

-

Cu 0)C 0 0 c

Cu Cu

o

0

0

_-

s I0



E

ID i c -i~~~~

-i

>

>

>

-i

C.)

-j

-,

>

0 0

0

I-.0

0



>

>

C

CC

C

0

al

0

4-s0

aL

>

LC

>

>

1II Ei

.

COC 4-,0 C OOD *,

>

o O@

c

() X-

ci)

+

0

o co

a

.

0

co__r

Q

a) L0n

C C

.5 C

C)

2

C~

(I)

0 a)

0

-C 0 a)

° 0 °0

-0r-C -o

0 0

0 C~ C~ N (sc

C~

O

Q

a)

L-

-

0

a)

a

CD 0

+

C

CO~~E 0 Q4+' 2 ,C /( C-~, (NcsO

N

0

c C

Q4-L. *4*-, iC (NO)N

co

a) (N

ac0

-~ CN>

U)

C

o

0

-

>0 4._.

cn 0

E

E

.0

0

E

CD

E

0

4

0

)C

0

00) 0 OL

0

0

00a

0

0

0

0

4U

Z

co +

4'

000C:

E

M

0

0

Q

0~a 00 n0> o 11 > cn

o0

40

CO

C'


>

C al) co> Q

> X co

0

0C

S

.0 a 0 U)

0 >> 00( o

-x

=

C)

N

(Nq

IC

LO

LO

(N

CN

(N

0)

J14

1-

CY)

,t

L-) >0 > .QaD-a ~co. E

C'1

0)

0

0C C.)

>

00 (D

.._

i-C

0

s

cro o a)

I"

a) >w)

II

Te-cas Heart Institutejournal

co CY)

c~ (U)

co

-o

co

N a

aOD))va

20

)

0

0

co0

'a)

co

E~

FELF a)>-C"_

> 0 )

*

*

*

LL