From the Guidelines
Surgical excision of the tumor is the recommended management approach for a patient with papillary fibroelastoma who has experienced a stroke, as it has been associated with a decreased risk of stroke compared to conservative management. The decision to proceed with surgery is based on the high risk of embolic events associated with these tumors, as highlighted in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. According to this guideline, cardiac tumors, including papillary fibroelastomas, can cause stroke through embolization of tumor fragments or attached thrombi, and surgical excision is the only established treatment option.
While awaiting surgery, anticoagulation therapy should be initiated to reduce the risk of recurrent embolic events. This can be achieved with intravenous heparin transitioning to warfarin with a target INR of 2.0-3.0, or direct oral anticoagulants like apixaban 5mg twice daily. For patients who are not surgical candidates due to comorbidities or high operative risk, lifelong anticoagulation is recommended. The surgical approach typically involves complete excision of the tumor with preservation of the underlying valve structure when possible, as papillary fibroelastomas are benign cardiac tumors that often attach to heart valves.
Key considerations in the management of papillary fibroelastoma include:
- The risk of embolic events, which can be reduced with surgical excision 1
- The importance of anticoagulation therapy while awaiting surgery or for patients who are not surgical candidates
- The need for regular echocardiographic follow-up to monitor for recurrence after surgery, although this is rare after complete excision. As noted in the guidelines for the primary prevention of stroke, surgical intervention is recommended for symptomatic fibroelastomas and for fibroelastomas that are >1 cm in diameter or appear mobile, even if asymptomatic, because they pose a risk for embolism 1.
From the Research
Management Approach for Papillary Fibroelastoma with Stroke
The management approach for a patient with papillary fibroelastoma who has experienced a stroke involves surgical excision of the tumor to prevent further embolic complications 2, 3, 4, 5, 6.
- Surgical Excision: The primary indication for surgery is the presence of papillary fibroelastoma, especially in patients with a history of stroke or transient ischemic attack 3.
- Valve Preservation: In most cases, valve shave is sufficient, and the native valve can be preserved 3.
- Low Operative Mortality: The operative mortality rate is low, ranging from 0% to 2.5% 3.
- Low Risk of Neurologic Events: The risk of early neurologic events is low, approximately 1.3% 3.
- Excellent Long-term Outcomes: The long-term postoperative prognosis is excellent, with an estimated survival rate of 78.4% at 10 years for patients with primary papillary fibroelastoma 3.
- Importance of Early Diagnosis: Early diagnosis and treatment are crucial to reduce the risk of embolic events and improve outcomes 4, 5, 6.
- Role of Imaging Modalities: Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are essential diagnostic tools for characterizing cardiac masses and identifying sources of embolism 2, 4, 5, 6.