Cardiac Papillary Fibroelastoma: A Treatable Cause of Transient Ischemic Attack and Ischemic Stroke Detected by Transesophageal Echocardiography
1995; Elsevier BV; Volume: 70; Issue: 9 Linguagem: Inglês
10.4065/70.9.863
ISSN1942-5546
AutoresRobert D. Brown, Bijoy K. Khandheria, William D. Edwards,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoTransesophageal echocardiography (TEE) is used frequently in patients with cerebrovascular ischemia. On TEE, a typical appearance of a cardiac flbroelastoma is that of a pedunculated, mobile mass attached to a leaflet of a valve. Surgical excision of the lesion may lead to resolution of the symptoms and prevent further cerebrovascular ischemic events; valve replacement is seldom necessary. Herein we describe three patients with cerebral or ocular ischemia in whom histologic study confirmed a cardiac papillary tibroelastoma after initial detection by TEE. Cardiac papillary fibroelastomas should be considered in the differential diagnosis of transient ischemic attack and stroke, even in cases of recurrent events in the same vascular distribution. Although the use of echocardiography in the evaluation of stroke and transient ischemic attack is controversial, TEE must be considered in patients in whom the cause of cerebrovascular ischemia is unclear after noninvasive neurovascular studies or transthoracic echocardiography, even if the patient's cardiac history and the findings on physical examination are normal. Transesophageal echocardiography (TEE) is used frequently in patients with cerebrovascular ischemia. On TEE, a typical appearance of a cardiac flbroelastoma is that of a pedunculated, mobile mass attached to a leaflet of a valve. Surgical excision of the lesion may lead to resolution of the symptoms and prevent further cerebrovascular ischemic events; valve replacement is seldom necessary. Herein we describe three patients with cerebral or ocular ischemia in whom histologic study confirmed a cardiac papillary tibroelastoma after initial detection by TEE. Cardiac papillary fibroelastomas should be considered in the differential diagnosis of transient ischemic attack and stroke, even in cases of recurrent events in the same vascular distribution. Although the use of echocardiography in the evaluation of stroke and transient ischemic attack is controversial, TEE must be considered in patients in whom the cause of cerebrovascular ischemia is unclear after noninvasive neurovascular studies or transthoracic echocardiography, even if the patient's cardiac history and the findings on physical examination are normal. Papillary fibroelastomas are rare, histologically benign tumors that are most commonly detected on the cardiac valves but rarely on the endocardium.1McAllister Jr, HA Fenoglio Jr, JJ Tumors of the cardiovascular system.in: Atlas of Tumor Pathology. Fascicle 15, Second Series. Armed Forces Institute of Pathology, Washington (DC)1978: 20-25Google Scholar, 2Chitwood Jr, WR Cardiac neoplasms: current diagnosis, pathology, and therapy.J Card Surg. 1988; 3: 119-154Crossref PubMed Scopus (123) Google Scholar These tumors have typically been considered of little clinical significance, although recent reports suggest a possible association with sudden death3Zull DN Diamond M Beringer D Angina and sudden death resulting from papillary fibroelastoma of the aortic valve.Ann Emerg Med. 1985; 14: 470-473Abstract Full Text PDF PubMed Scopus (41) Google Scholar and stroke.4Kasarskis EJ O'Connor W Earle G Embolic stroke from cardiac papillary fibroelastomas.Stroke. 1988; 19: 1171-1173Crossref PubMed Scopus (76) Google Scholar, 5McFadden PM Lacy JR Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.Ann Thorac Surg. 1987; 43: 667-669Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Yater WM Tumors of the heart and pericardium: pathology symptomatology and report of nine cases.Arch Intern Med. 1931; 48: 627-666Crossref Scopus (70) Google Scholar, 7Topol EJ Biern RO Reitz BA Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide to excision.Am J Med. 1986; 80: 129-132Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 8Ong LS Nanda NC Barold SS Two-dimensional echocardiographic detection and diagnostic features of left ventricular papillary fibroelastoma.Am Heart J. 1982; 103: 917-918Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 9Fowles RE Miller DC Egbert BM Fitzgerald JW Popp RL Systemic embolization from a mitral valve papillary endocardial fibroma detected by two-dimensional echocardiography.Am Heart J. 1981; 102: 128-130Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 10Abu Nassar SG Parker Jr, JC Incidental papillary endocardial tumor: its potential significance.Arch Pathol. 1971; 92: 370-376PubMed Google Scholar Technologic improvements in echocardiography have increased premorbid diagnosis,11Shub C Tajik AJ Seward JB Edwards WD Pruitt RD Orszulak TA et al.Cardiac papillary fibroelastomas: two-dimensional echocardiographic recognition.Mayo Clin Proc. 1981; 56: 629-633PubMed Google Scholar, 12Seward JB Khandheria BK Oh JK Abel MD Hughes Jr, RW Edwards WD et al.Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications.Mayo Clin Proc. 1988; 63: 649-680Abstract Full Text Full Text PDF PubMed Scopus (736) Google Scholar, 13Seward JB Khandheria BK Freeman WK Oh JK Enriquez-Sarano M Miller FA et al.Multiplane transesophageal echocardiography: image orientation, examination technique, anatomic correlations, and clinical applications.Mayo Clin Proc. 1993; 68: 523-551Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar and many patients have undergone surgical excision. There are no reports of patients treated with anticoagulation without surgical intervention. Herein we report three cases of cardiac fibroelastomas associated with cerebrovascular ischemia. Two patients had single, isolated events, whereas the third experienced numerous transient ischemic attacks (TIAs) in the same carotid arterial distribution. In all three patients, the papillary fibroelastoma was detected by transesophageal echocardiography (TEE) after neurovascular studies and transthoracic echocardiography (TTE) showed normal findings. Of 14 patients with histologic confirmation of aortic, mitral, or left ventricular outflow tract cardiac papillary fibroelastoma examined at the Mayo Clinic between 1988 and 1993, three experienced probable cardioembolic cerebral ischemic events. None of the other patients had symptoms related to the benign cardiac tumor. In three patients, a fortuitous diagnosis was made at autopsy. Surgical indications in the other eight patients included heart transplantation (in one), aortic aneurysm (in one), new cardiac auscultatory finding and echocardiographic confirmation of a mitral mass (in one), ventricular septal defect (in one), left ventricular outflow obstruction (in two), and coronary artery disease (in two). Case 1.—A 55-year-old woman sought medical treatment because of two episodes of acute onset of weakness and sensory loss of a few minutes' duration in the right upper extremity. No other associated symptoms were evident, and she experienced no problems between episodes. The patient's pertinent medical history was an aneurysmal subarachnoid hemorrhage and repair of an aneurysm of the right anterior communicating artery 10 years before the current admission. No other clinically significant history was noted; specifically, she had no cardiac disease, and she was taking no medications. Results of neurologic, neurovascular, and cardiac examinations were normal. Computed tomography of the brain revealed the previous craniotomy site; otherwise, findings were normal. Treatment with intravenously administered heparin was initiated, and a workup ensued. Results of general blood tests, special coagulation studies, multiple blood cultures, chest roentgenography, and electrocardiography were normal or negative. Findings on ocular pneumoplethysmography, carotid ultrasonography, transcranial Doppler examination of the anterior circulation, and cerebral angiography were normal. Results of TTE were normal; the size of the left atrium was in the upper limit of the normal range. TEE demonstrated several highly mobile filamentous echodensities attached to the aortic valve, with the largest lesion being 8 mm by 3 mm (Fig. 1). The nature of the valvular abnormality could not be defined with certainty. The patient decided to try anticoagulant therapy with warfarin sodium until symptoms recurred or until a scheduled reassessment 3 months later. The patient had four more transient episodes of right upper extremity clumsiness and acute onset of sensory disturbance while she was receiving warfarin sodium, with therapeutic prothrombin times of 1.5 to 1.8 times normal (the international normalized ratio was unavailable). Weakness in the right lower extremity without arm involvement occurred on one occasion. Use of warfarin was continued, and she returned 4 months later for further assessment. Findings on TEE were unchanged. At operation, six cordlike fibrous fronds consistent histologically with papillary fibroelastomas were resected from the aortic valve; they were 1 mm in diameter and ranged between 4 and 7 mm in length. Fine, feathery projections without adherent thrombus were evident on microscopy (Fig. 2). Postoperatively, the patient had an uneventful recovery and continued taking warfarin for 3 months. During the next 3 years, she had no further symptoms of cere brovascular ischemia. Case 2.—A 40-year-old woman had experienced good health until abrupt onset of clumsiness in the right upper extremity, followed by right lower extremity weakness and right facial droop. Throughout the next 48 hours, her condition slowly improved to normal. She had no previous neurologic problems except for a diagnosis of carpal tunnel syndrome. Results of neurologic and general physical examinations were normal. Magnetic resonance imaging of the head revealed a left frontal infarction. Findings on noninvasive neurovascular and extensive coagulation studies were normal, as were those on TTE. TEE showed a pedunculated mass (5 mm by 6 mm) on the anterior leaflet of the mitral valve (Fig. 3). At operation, a papillary fibroelastoma was noted to be attached to the chordae next to the midportion of the anterior mitral leaflet and at the junction of the chordae and anterior mitral leaflet. The lesion was excised. The patient did well, and no further neurologic events have occurred. Case 3.—A 68-year-old man awakened with impairment of vision in his right eye. He had no previous neurologic or neurovascular problems. Pertinent medical history included coronary artery bypass grafting 11 years before the ocular event. He reported some chest discomfort when walking and had previously smoked cigarettes, although he had quit 10 years earlier. Results of neurologic and general physical examinations were normal. An ophthalmologic examination revealed retinal pallor and thinned arteries, findings thought to be consistent with occlusion of a central retinal artery. Results of a carotid ultrasound study were normal. TTE showed no valvular abnormality. TEE revealed a small pedunculated mass (6 mm by 4 mm) attached to the ventricular surface of the left coronary cusp (Fig. 4). He was treated with warfarin and had no further events during the next 4 months. A surgical procedure, including coronary artery bypass grafting, was performed, and a sessile, pedunculated lesion was removed from the ventricular surface of the left cusp of the aortic valve. A small fibrous tag was removed from the right cusp. Histologically, the lesions were consistent with papillary fibroelastomas; no microscopic thrombus was noted. Postoperatively, the patient did well, had no evidence of valvular insufficiency, and had no further neurovascular spells. Although cardiac papillary fibroelastomas have been considered as incidental findings at autopsy or operation, they may be a curable, albeit rare, cause of systemic emboli. Previous studies have been unable to define a clear causative role of the cardiac lesion. Nonetheless, absence of an alternative cause of embolic symptoms.3Zull DN Diamond M Beringer D Angina and sudden death resulting from papillary fibroelastoma of the aortic valve.Ann Emerg Med. 1985; 14: 470-473Abstract Full Text PDF PubMed Scopus (41) Google Scholar, 4Kasarskis EJ O'Connor W Earle G Embolic stroke from cardiac papillary fibroelastomas.Stroke. 1988; 19: 1171-1173Crossref PubMed Scopus (76) Google Scholar, 5McFadden PM Lacy JR Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.Ann Thorac Surg. 1987; 43: 667-669Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Yater WM Tumors of the heart and pericardium: pathology symptomatology and report of nine cases.Arch Intern Med. 1931; 48: 627-666Crossref Scopus (70) Google Scholar, 7Topol EJ Biern RO Reitz BA Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide to excision.Am J Med. 1986; 80: 129-132Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 8Ong LS Nanda NC Barold SS Two-dimensional echocardiographic detection and diagnostic features of left ventricular papillary fibroelastoma.Am Heart J. 1982; 103: 917-918Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 9Fowles RE Miller DC Egbert BM Fitzgerald JW Popp RL Systemic embolization from a mitral valve papillary endocardial fibroma detected by two-dimensional echocardiography.Am Heart J. 1981; 102: 128-130Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 10Abu Nassar SG Parker Jr, JC Incidental papillary endocardial tumor: its potential significance.Arch Pathol. 1971; 92: 370-376PubMed Google Scholar histologic confirmation of thrombus adherent to the tumor surface.5McFadden PM Lacy JR Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.Ann Thorac Surg. 1987; 43: 667-669Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 9Fowles RE Miller DC Egbert BM Fitzgerald JW Popp RL Systemic embolization from a mitral valve papillary endocardial fibroma detected by two-dimensional echocardiography.Am Heart J. 1981; 102: 128-130Abstract Full Text PDF PubMed Scopus (62) Google Scholar and resolution of recurrent symptoms after surgical resection as reported herein make the papillary fibroelastoma a likely embolic source. Mitral and aortic lesions may also be noted fortuitously in the absence of clinical symptom11Shub C Tajik AJ Seward JB Edwards WD Pruitt RD Orszulak TA et al.Cardiac papillary fibroelastomas: two-dimensional echocardiographic recognition.Mayo Clin Proc. 1981; 56: 629-633PubMed Google Scholar or may manifest with cardiac complications, including angina,3Zull DN Diamond M Beringer D Angina and sudden death resulting from papillary fibroelastoma of the aortic valve.Ann Emerg Med. 1985; 14: 470-473Abstract Full Text PDF PubMed Scopus (41) Google Scholar myocardial infarction,14Mazzucco A Faggian G Bortolotti U Bonato R Pittarello D Centonze G et al.Embolizing papillary fibroelastoma of the mitral valve.Tex Heart Inst J. 1991; 18: 62-66PubMed Google Scholar or sudden death,3Zull DN Diamond M Beringer D Angina and sudden death resulting from papillary fibroelastoma of the aortic valve.Ann Emerg Med. 1985; 14: 470-473Abstract Full Text PDF PubMed Scopus (41) Google Scholar The incidence and prevalence of these tumors in the general population are unknown. In one autopsy series, fibroelastomas constituted 7% of all cardiac tumors detected,15Prichard RW Tumors of the heart: review of the subject and report of one hundred and fifty cases.Arch Pathol Lab Med. 1951; 51: 98-128Google Scholar and primary cardiac tumors have been noted in 0.002 to 0.33% of autopsies.2Chitwood Jr, WR Cardiac neoplasms: current diagnosis, pathology, and therapy.J Card Surg. 1988; 3: 119-154Crossref PubMed Scopus (123) Google Scholar No data are available on the incidence in asymptomatic patients, from either autopsy or echocardiographic series. Previous case reports have described eight patients with cerebrovascular symptoms associated with cardiac papillary fibroelastomas.4Kasarskis EJ O'Connor W Earle G Embolic stroke from cardiac papillary fibroelastomas.Stroke. 1988; 19: 1171-1173Crossref PubMed Scopus (76) Google Scholar, 5McFadden PM Lacy JR Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.Ann Thorac Surg. 1987; 43: 667-669Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 6Yater WM Tumors of the heart and pericardium: pathology symptomatology and report of nine cases.Arch Intern Med. 1931; 48: 627-666Crossref Scopus (70) Google Scholar, 7Topol EJ Biern RO Reitz BA Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide to excision.Am J Med. 1986; 80: 129-132Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 8Ong LS Nanda NC Barold SS Two-dimensional echocardiographic detection and diagnostic features of left ventricular papillary fibroelastoma.Am Heart J. 1982; 103: 917-918Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 9Fowles RE Miller DC Egbert BM Fitzgerald JW Popp RL Systemic embolization from a mitral valve papillary endocardial fibroma detected by two-dimensional echocardiography.Am Heart J. 1981; 102: 128-130Abstract Full Text PDF PubMed Scopus (62) Google Scholar, 10Abu Nassar SG Parker Jr, JC Incidental papillary endocardial tumor: its potential significance.Arch Pathol. 1971; 92: 370-376PubMed Google Scholar The age of the patients at diagnosis ranged between 27 and 70 years. Six patients had infarcts in a middle cerebral artery distribution, and one had multifocal cerebral infarction. Only one patient had a TIA without infarction; this patient underwent surgical treatment after the first event.4Kasarskis EJ O'Connor W Earle G Embolic stroke from cardiac papillary fibroelastomas.Stroke. 1988; 19: 1171-1173Crossref PubMed Scopus (76) Google Scholar Two patients had histologic confirmation of thrombus adherent to the fronds of the tumor surface.5McFadden PM Lacy JR Intracardiac papillary fibroelastoma: an occult cause of embolic neurologic deficit.Ann Thorac Surg. 1987; 43: 667-669Abstract Full Text PDF PubMed Scopus (71) Google Scholar, 9Fowles RE Miller DC Egbert BM Fitzgerald JW Popp RL Systemic embolization from a mitral valve papillary endocardial fibroma detected by two-dimensional echocardiography.Am Heart J. 1981; 102: 128-130Abstract Full Text PDF PubMed Scopus (62) Google Scholar In the past, the tumor was surgically excised, if possible. Use of warfarin anticoagulant treatment has not been previously reported. Detection of these benign tumors before surgical excision or autopsy is common because of increasingly sophisticated methods of characterizing the cardiac anatomy.11Shub C Tajik AJ Seward JB Edwards WD Pruitt RD Orszulak TA et al.Cardiac papillary fibroelastomas: two-dimensional echocardiographic recognition.Mayo Clin Proc. 1981; 56: 629-633PubMed Google Scholar, 12Seward JB Khandheria BK Oh JK Abel MD Hughes Jr, RW Edwards WD et al.Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications.Mayo Clin Proc. 1988; 63: 649-680Abstract Full Text Full Text PDF PubMed Scopus (736) Google Scholar, 13Seward JB Khandheria BK Freeman WK Oh JK Enriquez-Sarano M Miller FA et al.Multiplane transesophageal echocardiography: image orientation, examination technique, anatomic correlations, and clinical applications.Mayo Clin Proc. 1993; 68: 523-551Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar Two-dimensional echocardiography may reveal the presence of large lesions,11Shub C Tajik AJ Seward JB Edwards WD Pruitt RD Orszulak TA et al.Cardiac papillary fibroelastomas: two-dimensional echocardiographic recognition.Mayo Clin Proc. 1981; 56: 629-633PubMed Google Scholar but findings may be normal, as in our patients. Typical findings are pedunculated, mobile masses attached to the leaflets of the valve. The attachment site of the lesion may not be detectable by transthoracic study; thus, distinguishing vegetations from thrombus is difficult. The current case series exemplify the need for TEE for TIA not explained by other causes. Numerous recent studies that have evaluated the need for echocardiography in the assessment of stroke and TIA have demonstrated an infrequent change in management based on echocardiographic findings.16Robbins JA Sagar KB French M Smith PJ Influence of echocardiography on management of patients with systemic emboli.Stroke. 1983; 14: 546-549Crossref PubMed Scopus (26) Google Scholar, 17Greenland P Knopman DS Mikell FL Asinger RW Anderson DC Good DC Echocardiography in diagnostic assessment of stroke.Ann Intern Med. 1981; 95: 51-53Crossref PubMed Scopus (97) Google Scholar, 18Lovett JL Sandok BA Giuliani ER Nasser FN Two-dimensional echocardiography in patients with focal cerebral ischemia.Ann Intern Med. 1981; 95: 1-4Crossref PubMed Scopus (86) Google Scholar, 19Good DC Frank S Verhulst S Sharma B Cardiac abnormalities in stroke patients with negative arteriograms.Stroke. 1986; 17: 6-11Crossref PubMed Scopus (45) Google Scholar, 20Cujec B Polasek P Voll C Shuaib A Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients.Stroke. 1991; 22: 727-733Crossref PubMed Scopus (194) Google Scholar, 21Mosewich RK Shuaib A Cujec B Polasek P Impact of transesophageal echocardiogram on the management of acute stroke.J Stroke Cerebrovasc Dis. 1993; 3: 57-60Abstract Full Text PDF Scopus (3) Google Scholar, 22Pop G Sutherland GR Koudstaal PJ Sit TW de Jong G Roelandt JR Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks.Stroke. 1990; 21: 560-565Crossref PubMed Scopus (201) Google Scholar, 23Zenker G Erbel R Krämer G Mohr-Kahaly S Drexler M Harnoncourt K et al.Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events.Stroke. 1988; 19: 345-348Crossref PubMed Scopus (84) Google Scholar, 24de Belder MA Lovat LB Tourikis L Leech G Camm AJ Limitations of transesophageal echocardiography in patients with focal cerebral ischaemic events.Br Heart J. 1992; 67: 297-303Crossref PubMed Scopus (31) Google Scholar, 25Lee RJ Bartzokis T Yeoh TK Grogin HR Choi D Schnittger I Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography.Stroke. 1991; 22: 734-739Crossref PubMed Scopus (221) Google Scholar In a review of 63 patients with TIA or stroke who underwent TTE and TEE, no abnormalities were deteeted on TTE in those patients who had normal findings on a cardiac physical examination, electrocardiography, and cardiac clinical history. Results on TEE were “abnormal” in only seven patients: two had patent foramen ovale and right-to-left shunting, two had a myxomatous mitral valve, two had atrial septal aneurysms, and one had a left atrial appendage thrombus.20Cujec B Polasek P Voll C Shuaib A Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients.Stroke. 1991; 22: 727-733Crossref PubMed Scopus (194) Google Scholar Management was altered by the findings on TEE in 5% of patients.21Mosewich RK Shuaib A Cujec B Polasek P Impact of transesophageal echocardiogram on the management of acute stroke.J Stroke Cerebrovasc Dis. 1993; 3: 57-60Abstract Full Text PDF Scopus (3) Google Scholar Other investigators have noted a higher occurrence of possible valvular disease that may predispose to cardioembolic events.25Lee RJ Bartzokis T Yeoh TK Grogin HR Choi D Schnittger I Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography.Stroke. 1991; 22: 734-739Crossref PubMed Scopus (221) Google Scholar, 26Todnem K Vik-Mo H Cerebral ischemic attacks as a complication of heart disease: the value of echocardiography.Acta Neurol Scand. 1986; 74: 323-327Crossref PubMed Scopus (15) Google Scholar Lee and associates25Lee RJ Bartzokis T Yeoh TK Grogin HR Choi D Schnittger I Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography.Stroke. 1991; 22: 734-739Crossref PubMed Scopus (221) Google Scholar assessed 50 consecutive hospitalized patients with recent TIA or stroke of probable embolic origin and compared findings on TEE to those on TTE. Twenty-six patients had abnormal findings on TEE, including 11 with “highly mobile filamentous strands on the mitral valve.” Possibly, a small percentage of these abnormalities were cardiac fibroelastomas, although pathologic confirmation and data on the change in treatment due to results of the cardiac studies were unavailable. In one of our patients (case 1), several factors should be emphasized. The temporal correlation of the disappearance of the TIAs after the valve operation makes it likely that all the transient cerebrovascular symptoms were caused by cardioembolic ischemic events. Recurrent events in the same vascular distribution are uncommonly considered cardiac in nature, and case 1 reinforces the need for cardiac imaging if another cause cannot be found. This is the first reported case of long-term warfarin anticoagulant therapy in a patient with active embolic events caused by a fibroelastoma. Although the warfarin anticoagulant treatment was ineffective in this patient, generalizations for other patients with this type of lesion cannot be made on the basis of a single report. Curative surgical treatment before cerebral infarction has been noted in only one of eight other patients with cerebral cardioembolic events due to cardiac fibroelastoma. The importance of cardiac fibroelastomas in the epidemiology of TIA and stroke should not be overestimated. Cardioembolic events are uncommonly caused by this rare, histologically benign lesion. Nonetheless, this tumor should be considered in the differential diagnosis of cerebral ischemia, even in cases of recurrent events in the same vascular distribution. Cardiac imaging with TEE should be considered if an alternative cause for the events is not found. The most reasonable use of echocardiography in the evaluation of stroke and TIA is controversial; the cases presented herein demonstrate a curable cause of ischemic neurovascular disease, detected before major cerebral infarction, that would have been overlooked if TEE had not been performed. Treatment of cardiac fibroelastomas is controversial because minimal data are available about therapeutic efficacy. Symptomatic lesions may be conservatively managed initially with anticoagulant therapy, although any recurrent ischemic events should prompt surgical excision of the fibroelastoma to prevent further cerebral and systemic embolic events; typically, valve replacement is unnecessary. In young patients with no alternative explanation for the ischemic symptoms despite a comprehensive workup, an operation may be the recommended initial treatment approach. Small, asymptomatic lesions detected on echocardiography performed for some other reason can usually be treated conservatively. Warfarin, antiplatelet therapy, or a combination of these should be considered in light of the fact that fibroelastomas serve as a nidus for thrombus formation. Early surgical excision of lesions close to the coronary ostia and of large lesions attached to the aortic valve may be considered because of risk of complications, including cardiac ischemia and sudden death. We thank Melissa L. Albrecht for her efficient and meticulous preparation of the submitted manuscript.
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