Scientific letter
Atrioventricular block due to papillary fibroelastoma
Bloqueo auriculoventricular por fibroelastoma papilar
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(1–3) Haematoxylin–eosin staining, at various magnifications ×10, ×15 and ×30, respectively. The images show a thyroid parenchyma with intense chronic lymphoplasmacytic inflammatory infiltrate (*), which disassociates the thyroid follicles, together with the neoplasm (**) consisting of connective axes lined by cells with large eosinophilic cytoplasm and nuclei with clefts in the nuclear membrane. The surrounding stroma has an intense lymphoplasmacytic inflammatory infiltrate with formation of primary germinal centre lymphoid aggregates. (4) Immunohistochemical staining for cytokeratin 19. 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style=""></span>Ft: soluble transferrin receptor ratio/log ferritin concentration; MCV: mean corpuscular volume; ESR: erythrocyte sedimentation rate.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: adapted from Muñoz al.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">50</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Susana Gómez Ramírez, Ángel Francisco Remacha Sevilla, Manuel Muñoz Gómez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Susana" "apellidos" => "Gómez Ramírez" ] 1 => array:2 [ "nombre" => "Ángel Francisco" "apellidos" => "Remacha Sevilla" ] 2 => array:2 [ "nombre" => "Manuel" "apellidos" => "Muñoz Gómez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775317305110" "doi" => "10.1016/j.medcli.2017.06.025" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => 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=> array:1 [ 0 => "tatojar@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ana María" "apellidos" => "Correa-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Isabel" "apellidos" => "Viqueira-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bloqueo auriculoventricular por fibroelastoma papilar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Papillary fibroelastoma (PF) is a rare tumour, constituting less than 10% of cardiac tumours examined in autopsies and in surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The medical literature usually states that PF is the third most common tumour, after myxoma and fibroma,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> but recent studies put it in first place.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> They are mainly located at the valvular level and are rarely dysfunctional: only tumours located on the left are associated with acute coronary syndromes, transient ischaemic attacks and sudden death.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> We report the case of a male patient who presents with a complete atrioventricular block associated with an unusual PF.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The 72-year-old male patient was being treated with metformin, liraglutide, insulin detemir, valsartan, furosemide, diltiazem and acenocumarol for hypertension, type 2 diabetes and paroxysmal atrial fibrillation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He visited ER after experiencing dizziness associated with nausea and vomiting which had 48<span class="elsevierStyleHsp" style=""></span>h of evolution. The clinical examination showed a heart rate of 30<span class="elsevierStyleHsp" style=""></span>bpm associated with blood pressure of 180/80<span class="elsevierStyleHsp" style=""></span>mmHg, with no other relevant clinical findings.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the analysis, an INR of 3.86 and an ultrasensitive T-troponin of 93<span class="elsevierStyleHsp" style=""></span>ng/l was observed, with no elevation in subsequent tests. The rest of the analysis did not show significant alterations.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The electrocardiogram showed a complete atrioventricular block with a ventricular escape rate of 30<span class="elsevierStyleHsp" style=""></span>bpm. The transthoracic echocardiogram showed a mobile and pediculated mass of 5<span class="elsevierStyleHsp" style=""></span>mm in diameter at the left ventricular outflow tract and the rest of the echocardiographic examination was normal. Coronary angiography showed no significant lesions.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We decided to implant a permanent pacemaker in DDDR mode and proceeded to the resection of the tumour mass, with good clinical evolution and without any complications. The anatomopathological study showed that the excised tissue was compatible with a PF.</p><p id="par0035" class="elsevierStylePara elsevierViewall">PF was initially described by Yatern in 1931 as a valvular tumour and following that Cheitlin coined the term. Cases range from the ages of neonatal to 100, predominating between the ages of 40 and 80, and especially affecting males, as reflected in our patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">They are located mainly at the valvular level, although they can affect any part of the heart, with predominance in the left cavities, and less frequently in the left ventricular outflow tract.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Clinical manifestations, when present (60% are asymptomatic), are predominantly cardiovascular and differ according to different factors: location, size, growth rate and tendency of tumour embolisation; the most frequent are cerebral, systemic and coronary embolisms, followed by heart failure and sudden death. The presence of conduction disorders, as in our patient, is unusual, there are only two cases described in the medical literature.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In most cases, PF is diagnosed by chance through a transthoracic echocardiogram (TTE) or an autopsy. Although TTE is useful for diagnosis, a transesophageal echocardiography allows us to differentiate it from myxomas. A differential diagnosis is established with myxoma, fibroids, vegetations, thrombi, Lambl's excrescences and cord rupture.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical excision is curative and indicated for symptomatic patients, prolonged follow-up is recommended as recurrences may occur. There are controversies regarding the treatment of asymptomatic patients, as treatment should be personalised on a case by case basis. According to studies, PF located on the left side should be removed because of its high risk of systemic embolism.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, PF is a rare tumour, whose clinical symptoms are variable and related to embolic processes. However, conduction disorders should be considered to be associated with these types of cardiac tumours, especially those affecting the left ventricular outflow tract.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Amao-Ruiz E, Correa-Fernández AM, Viqueira-Rodríguez I. Bloqueo auriculoventricular por fibroelastoma papilar. Med Clin (Barc). 2017;149:504–505.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary cardiac tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Maraj" 1 => "G.S. Pressman" 2 => "V.M. 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Shahian" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Semin Thorac Cardiovasc Surg" "fecha" => "2000" "volumen" => "12" "paginaInicial" => "101" "paginaFinal" => "110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10807432" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014900000011/v1_201712130718/S2387020617306939/v1_201712130718/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014900000011/v1_201712130718/S2387020617306939/v1_201712130718/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020617306939?idApp=UINPBA00004N" ]
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