Percutaneous Removal of Cardiac Papillary Fibroelastomas

Figures

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  Figure 1. Percutaneous Mechanical Aspiration of Small PFE (A) Echocardiographic imaging of the papillary fibroelastoma (PFE) (yellow asterisk) before attempted removal. (B) Fluoroscopic visualization of the snare (yellow arrow) steering the Penumbra Lightning 12 (PL12) catheter (red arrow) to the PFE. (C and D) Multiplane imaging of the P12 catheter engaging with the PFE. (E and F) Despite repeated aspiration attempts, the PFE was still present at the end of the case.

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  Figure 2. Percutaneous Mechanical Aspiration of Mitral PFE (A and B) Transesophageal echocardiography findings of PFE on mitral valve (yellow asterisk). (C) Fluoroscopic imaging of the PL12 catheter (red arrow) directed toward the PFE across the interatrial septum. (D to F) Three-dimensional and multiplane images showing PL12 catheter engagement with the PFE. (G) Small residual PFE present after multiple aspiration attempts. (H) Surgical pathology confirming diagnosis of PFE. Abbreviations as in Figure 1.

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  Figure 3. Percutaneous Mechanical Aspiration of Large Aortic PFE (A and B) Preprocedural imaging showing large aortic papillary fibroelastoma (PFE) (yellow asterisk). (C and D) The AngioVac F18 catheter (blue arrow) with low suction speeds was used to engage the PFE and lock it in place. (E and F) Echocardiographic imaging of the snare (orange arrow) encircling the PFE. (G and H) Fluoroscopic imaging of the snare in conjunction with the AngioVac F18. (I and J) No residual PFE after the procedure. (K and L) New aortic regurgitation by echocardiography and fluoroscopy. (M) Transcatheter aortic valve replacement for aortic regurgitation was successful. (N and O) Gross specimen of collected PFE. (P) Histopathology confirming the diagnosis of PFE.

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  Figure 4. Percutaneous Mechanical Aspiration of Aortic Valve PFE (A) TEE revealed 9 × 6 mm aortic valve PFE. (B) F18 Angiovac was positioned retroaortic and flows were initated at low speeds, (C and D) a 25 mm Gooseneck snare (red arrows) positioned around the PFE and (E and F) tightened (green arrows) around the stalk of the PFE (white arrow). (G to K) PFE was successfully aspirated with no aortic injury and specimen was retrieved, and pathology confirmed PFE.

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  Figure 5. Percutaneous Mechanical Aspiration of Chordal PFE (A and B) TEE imaging showing the presence of the PFE (yellow asterisk) attached to the mitral chordal apparatus. (C) Three-dimensional model used for preprocedural planning showing the PFE (light blue mass) through the aortic valve, confirming feasibility of retroaortic approach. (D) AngioVac F18 cannula (blue arrow) engaging with the PFE while on low speed. (E) Fluoroscopic imaging of the AngioVac F18 from the retroaortic approach. (F) TEE imaging showing the complete removal of the PFE from the chordal apparatus. (G and H) Gross specimen of the collected PFE. (I) Histologic confirmation of PFE. Abbreviations as in Figure 1.

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  Figure 6. Approach for Percutaneous Mechanical Aspiration of PFE Using Continuous Flow and Concomitant Snare (A) Diagram of papillary fibroelastoma (PFE) attached to the aortic valve. (B) The inflow cannula approaches the PFE. (C) Low, continuous aspiration speeds are initiated to lock the PFE in place and reduce the risk of embolization. (D) While still on low speeds, a snare is introduced alongside the aspiration catheter and used to encircle the stalk of the PFE. (E) The aspiration catheter is advanced to engage the PFE, and the snare is slowly tightened. (F) Aspiration speeds are increased, and the snare is tightened and/or electrified until there is removal of the PFE (G).