Figure 3: Intraoperative view.
Figure 4: External view of the removed tumor.
Figure 5: Histopathological specimen with hematoxylin-eosin staining (H-E x 100).
Transthoracic echocardiography is the most common noninvasive method for diagnosis[5] since it shows the location of the tumor and reveals the relationship with adjacent structures. Transesophageal echocardiography can be used for a more detailed evaluation of left atrial and mitral valve involvement.[5]
Most of the reported cases involved patients who were diagnosed in their fourth or fifth decades.[5] Cardiac papillary fibroelastomas are usually symptomatic and smaller than 1 cm in diameter.[2,5] The thromboembolic complications of this disease cause symptoms such as transient ischemic attack, stroke, acute coronary syndrome, and pulmonary embolisms.[5] Surgical treatment, regardless of tumor size and location, is recommended for all CPFs to prevent such complications from occurring.[5,9] Our case suffered a stroke two years prior to his admission to our hospital and presented with left hemiparesis. Normally, it is preferable that cardiac surgery be performed approximately two months after the occurrence of a cerebrovascular accident.
The subvalvular left ventricular location in our patient was very rare, and exposure and excision of the tumor at this site can be difficult. The left atrial tissue was retracted using pledgeted sutures to expose the mitral valve, better visualize the subvalvular apparatus, and avoid a left ventriculotomy. In case of inadequate exposure of the tumor, guidance with a thoracoscope or flexible fiberscope can be an alternative.[10]
In conclusion, CPF situated in the subvalvular structure of the mitral valve is rarely seen, and resection of a tumor in this location can be a complicated procedure.
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