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Papers by Xavier Ruyra

Journal of Clinical and Experimental Cardiology, Dec 26, 2016

Cirugía Cardiovascular, 2021

Cardiology: Open Access, 2016

Background / Study Objective: Coronary artery disease is very common in patients who are referred... more Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, fem...

The Journal of heart valve disease, 1994

The case of the minor strut fracture of a Björk-Shiley convexo-concave mitral valve, with retrogr... more The case of the minor strut fracture of a Björk-Shiley convexo-concave mitral valve, with retrograde embolization to a pulmonary vein is presented. Migration probably occurred during ventricular systole and the strut became anchored to the pulmonary vein wall. The patient underwent emergency mitral valve replacement with event free recovery. The strut was located by computed tomography postoperatively, and it has remained in the same location for over one and a half years.

The Journal of Thoracic and Cardiovascular Surgery, 2004

Background: We prospectively evaluated a newly introduced minimal extracorporeal circulation syst... more Background: We prospectively evaluated a newly introduced minimal extracorporeal circulation system (Jostra MECC System; Jostra AG, Hirrlingen, Germany) for aortic valve surgery. Method: In a prospective, randomized study, 100 patients underwent aortic valve replacement either with standard cardiopulmonary bypass (n ϭ 50, group B) or with the MECC System (n ϭ 50, group B). The myocardial protection and the left vent were identical for the two groups. The intrapericardial suction device was never used (only the cell salvage device was used) to reduce the air-blood contact area. Results: No significant differences were noted in patient characteristics and operative data between groups. Operative mortality (Ͻ30 days) was 2% for group A and 4% for group B (difference not significant). From the preoperative period to the postoperative period, the increase in C-reactive protein was significantly higher for group B (P Ͻ .001). The postoperative troponin I level was significantly lower in group A (mean 4.65 Ϯ 2.9 g/L at 24 hours) than in group B (8.2 Ϯ 4.4 g/L, P Ͻ .03). On the other hand, the MECC System was associated with platelet preservation. Renal function was better preserved and the neurologic event rate was significantly lower for the MECC group (P Ͻ .02). Conclusion: The MECC System is safe and allows aortic valve replacement under the most favorable conditions. The system is more biocompatible than standard cardiopulmonary bypass and provides a good postoperative biologic profile and good clinical results, particularly for high-risk patients.

Journal of the American College of Cardiology, 2009

This study sought to report our experience with a routine completion angiogram after coronary art... more This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. Background The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Methods Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n ϭ 112) or without (n ϭ 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Results Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n ϭ 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n ϭ 48, 6%) or with traditional surgical revision (n ϭ 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Conclusions Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

The Annals of Thoracic Surgery, 1998

A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the... more A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the anterior leaflet of the mitral valve is reported. Excision of the tumor and mitral valve repair was performed. Four years later the child remains asymptomatic with no recurrence of the tumor or regurgitation.

European Journal of Anaesthesiology, 2005

aprotinin were excluded. We analysed the data of patients who received tranexamic acid (TA group)... more aprotinin were excluded. We analysed the data of patients who received tranexamic acid (TA group) with those who did not (NTA group). Our primary outcome measure was the exposure to packed red blood cells (RBC) following surgery in both groups. Our secondary outcome measures were the exposure to fresh frozen plasma (FFP) and total blood products, the proportion of patients returned to theatre because of blood loss and length of ICU stay. We performed chi-squared tests to assess differences between the groups in the proportion of patients who received RBC or FFP or total blood products and who returned to theatre. We performed Mann-Whitney tests to assess differences between the distributions of the use of RBC, FFP and total blood products and the length of ICU stay. Then we used multivariate logistic regression to adjust for the effect of other variables: age, sex, bypass time, EuroSCORE, BMI, time period, surgery type, priority, aspirin use, clopidogrel use, consultant surgeon and consultant anaesthetist. Results: The TA group had 3359 (80.1%) patients and NTA group had 832 (19.9%) patients and exposure to blood products was 45.9% and 51.3% respectively (P ϭ 0.005). There was no statistical difference between the two groups in sex, BMI, surgery type and priority.

European Journal of Anaesthesiology, 2006

different mean arterial pressures (MAP, mmHg) on fluid extravasation during CPB in piglets. Mater... more different mean arterial pressures (MAP, mmHg) on fluid extravasation during CPB in piglets. Materials and Methods: 30 anaesthetised piglets underwent 60 min normothermic and 90 min hypothermic CPB before they were killed. CPB flow rate was set to 110 ml/kg/min. Fluid was added to keep a constant level in the machine reservoir. During CPB, 13 animals were given high MAP by norepinephrine (HP) while 9 animals had low MAP by nitroprussid (LP-N) and 8 animals had low MAP by phentolamine (LP-P). Fluid balance, hemodynamics, serum albumin (g/l) and plasmavolumes (CO-methode) (PV, ml/kg) were measured. Fluid extravasation rate (FER, ml/kg/min) was calculated. Statistical analysis by repeated measurements analysis with posttests (SPSS 13) Results as mean (SD). Results: ***: P Ͻ 0.001 compared with the other groups, same time. *: P Ͻ 0.05 compared with the LP-P, same time. Only statistics for between group differences are included. Conclusion: In this model, different MAP did not have a significant impact on fluid extravasation during CPB.

European Journal of Anaesthesiology, 2004

European Journal of Anaesthesiology, 2006

Tranexamic acid (TA) reduces blood loss in coronary artery surgery with cardiopulmonary bypass. T... more Tranexamic acid (TA) reduces blood loss in coronary artery surgery with cardiopulmonary bypass. The present prospective study was designed to investigate its hemostatic effect in off-pump coronary artery bypass (OPCAB). Seventy-six patients undergoing elective OPCAB were randomized into two groups, received TA (0.75 g loading dose before surgery and 250 mg/h during surgery, gross dose: 1.5 g, n=36) and saline solution (control, n=40), respectively. Perioperative blood samples were collected. Hematochemical parameters including platelet adhesion rate, D-dimer and fibrinopeptide-A (FPA) were analysis. Volume of blood loss, blood transfusion and other clinical data were recorded throughout the perioperative period. Cumulative blood loss was significantly reduced in the TA group as compared to the controls postoperatively (6 hrs (median [25th-75th]): TA: 200.0 [140.0-230.0] ml, 225.0 [200.0-347.5.0] ml, p=0.009; 24 hrs: TA: 440.0 [270.0-605.0] ml, 655.0 [500.0-920.0] ml, p<0.001). Number of patients received blood transfusion in each group was similar. Levels of D-dimer rose significantly after surgery, and were significantly lower in the TA group than that in controls. Platelet adhesion rate and FPA levels remained at baseline levels after the operation in two groups. Early clinical outcomes were similar between groups. The results indicated that tranexamic acid limits fibrinolysis and reduces blood loss after off-pump coronary artery bypass surgery.

Journal of Cardiac Surgery, 2008

Journal of Thoracic Disease, 2020

PloS one, 2018

The aim of the study was to analyse the presence of several metabolites related to atherosclerosi... more The aim of the study was to analyse the presence of several metabolites related to atherosclerosis in the plasma of patients with unstable carotid plaque and in the plasma of healthy subjects. We included 20 patients who had undergone carotid endarterectomy and 20 healthy subjects as a control group. All the subjects recruited were male. We used a metabolomic approach with liquid chromatography coupled to mass spectrometry to evaluate plasma metabolite levels in the metabolic pathway involved in the progression of atherosclerotic plaque. We observed that circulating levels of 20-HETE were significantly higher in patients with atheroma plaque than in healthy subjects (p = 0.018). No differences were found with regard to the other metabolites analysed. We also conducted a random forest analysis and found that 20-HETE was the main differentiator in the list of selected metabolites. In addition, plasma levels of 20-HETE correlated positively with body mass index (r = 0.427, p = 0.007) a...

Revista espanola de cardiologia (English ed.), Jan 17, 2017

Current postoperative management of adult cardiac surgery often comprises transfer from the inten... more Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus corona...

Revista Española de Cardiología (English Edition), 2017

A 45-year-old man with Crohn disease was referred for colectomy. Preoperative chest X-ray showed ... more A 45-year-old man with Crohn disease was referred for colectomy. Preoperative chest X-ray showed a right pulmonary hilum nodular image that prompted a thoracic computed tomography scan. Incidentally, a round mass was detected in the main pulmonary artery (Figure A, asterisk) and was further confirmed on computed tomography-angiography (Figure B-C; arrows; PA, pulmonary artery; RV, right ventricle). The patient denied prior chest pain, palpitations, dyspnea, or fever. Transthoracic and transesophageal echocardiography identified a round mass attached to the arterial side of the pulmonary valve, with no valve regurgitation. A magnetic resonance scan confirmed the presence of a 12-mm diameter mobile mass attached to the pulmonary valve, which was isointense on T 1-weighted images, highly hyperintense on T 2 , and was not perfused but was enhanced 10 minutes after gadolinium administration (Figure D-G, arrows; Video 1 of the supplementary material). Thus, the differential diagnosis between pulmonary valve papillary fibroelastoma and myxoma was established. Cardiac surgery was performed 1 month after colectomy. A well-defined round mucinous mass attached to the tip of the pulmonary valve was easily excised, with valve sparing (Figure H; Video 2 of the supplementary material). It consisted of an elongated and branching papillary proliferation covered by a single layer of cells (Figure I) on hematoxylin-eosin stain, which expressed endothelial cell markers (Figure J) on immunohistochemistry for erythroblast transformation-related gene, thus allowing diagnosis of papillary fibroelastoma. Papillary fibroelastomas are common, but not in a pulmonary position. The differential diagnosis with myxoma can be difficult, mainly if the masses are round-shaped. Magnetic resonance findings facilitate the diagnosis of a wide range of masses.

Journal of Clinical and Experimental Cardiology, Dec 26, 2016

Cirugía Cardiovascular, 2021

Cardiology: Open Access, 2016

Background / Study Objective: Coronary artery disease is very common in patients who are referred... more Background / Study Objective: Coronary artery disease is very common in patients who are referred to aortic valve replacement. Concomitant coronary artery bypass grafting (CABG) procedure does not necessarily contradict with the use of last generation sutureless bioprostheses, but, publications about this combined approach are very limited. The objective of this study is to describe the results of aortic valve replacement plus CABG using Perceval S aortic sutureless bioprostheses in our Center. Methods: From our database we retrospectively described the outcomes of 42 patients who underwent aortic valve replacement with a last generation sutureless bioprostheses (Perceval S) plus CABG at the same procedure. We used a combination of arterials (left internal mammary artery (LIMA), right internal mammary artery (RIMA) and radial artery) and saphenous vein for the coronary artery bypass grafting. Most of the patients received 1 bypass (range: 1-3). Mean age: 78,19 ± 5,1. Male 64,3%, fem...

The Journal of heart valve disease, 1994

The case of the minor strut fracture of a Björk-Shiley convexo-concave mitral valve, with retrogr... more The case of the minor strut fracture of a Björk-Shiley convexo-concave mitral valve, with retrograde embolization to a pulmonary vein is presented. Migration probably occurred during ventricular systole and the strut became anchored to the pulmonary vein wall. The patient underwent emergency mitral valve replacement with event free recovery. The strut was located by computed tomography postoperatively, and it has remained in the same location for over one and a half years.

The Journal of Thoracic and Cardiovascular Surgery, 2004

Background: We prospectively evaluated a newly introduced minimal extracorporeal circulation syst... more Background: We prospectively evaluated a newly introduced minimal extracorporeal circulation system (Jostra MECC System; Jostra AG, Hirrlingen, Germany) for aortic valve surgery. Method: In a prospective, randomized study, 100 patients underwent aortic valve replacement either with standard cardiopulmonary bypass (n ϭ 50, group B) or with the MECC System (n ϭ 50, group B). The myocardial protection and the left vent were identical for the two groups. The intrapericardial suction device was never used (only the cell salvage device was used) to reduce the air-blood contact area. Results: No significant differences were noted in patient characteristics and operative data between groups. Operative mortality (Ͻ30 days) was 2% for group A and 4% for group B (difference not significant). From the preoperative period to the postoperative period, the increase in C-reactive protein was significantly higher for group B (P Ͻ .001). The postoperative troponin I level was significantly lower in group A (mean 4.65 Ϯ 2.9 g/L at 24 hours) than in group B (8.2 Ϯ 4.4 g/L, P Ͻ .03). On the other hand, the MECC System was associated with platelet preservation. Renal function was better preserved and the neurologic event rate was significantly lower for the MECC group (P Ͻ .02). Conclusion: The MECC System is safe and allows aortic valve replacement under the most favorable conditions. The system is more biocompatible than standard cardiopulmonary bypass and provides a good postoperative biologic profile and good clinical results, particularly for high-risk patients.

Journal of the American College of Cardiology, 2009

This study sought to report our experience with a routine completion angiogram after coronary art... more This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. Background The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Methods Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n ϭ 112) or without (n ϭ 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Results Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n ϭ 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n ϭ 48, 6%) or with traditional surgical revision (n ϭ 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Conclusions Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

The Annals of Thoracic Surgery, 1998

A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the... more A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the anterior leaflet of the mitral valve is reported. Excision of the tumor and mitral valve repair was performed. Four years later the child remains asymptomatic with no recurrence of the tumor or regurgitation.

European Journal of Anaesthesiology, 2005

aprotinin were excluded. We analysed the data of patients who received tranexamic acid (TA group)... more aprotinin were excluded. We analysed the data of patients who received tranexamic acid (TA group) with those who did not (NTA group). Our primary outcome measure was the exposure to packed red blood cells (RBC) following surgery in both groups. Our secondary outcome measures were the exposure to fresh frozen plasma (FFP) and total blood products, the proportion of patients returned to theatre because of blood loss and length of ICU stay. We performed chi-squared tests to assess differences between the groups in the proportion of patients who received RBC or FFP or total blood products and who returned to theatre. We performed Mann-Whitney tests to assess differences between the distributions of the use of RBC, FFP and total blood products and the length of ICU stay. Then we used multivariate logistic regression to adjust for the effect of other variables: age, sex, bypass time, EuroSCORE, BMI, time period, surgery type, priority, aspirin use, clopidogrel use, consultant surgeon and consultant anaesthetist. Results: The TA group had 3359 (80.1%) patients and NTA group had 832 (19.9%) patients and exposure to blood products was 45.9% and 51.3% respectively (P ϭ 0.005). There was no statistical difference between the two groups in sex, BMI, surgery type and priority.

European Journal of Anaesthesiology, 2006

different mean arterial pressures (MAP, mmHg) on fluid extravasation during CPB in piglets. Mater... more different mean arterial pressures (MAP, mmHg) on fluid extravasation during CPB in piglets. Materials and Methods: 30 anaesthetised piglets underwent 60 min normothermic and 90 min hypothermic CPB before they were killed. CPB flow rate was set to 110 ml/kg/min. Fluid was added to keep a constant level in the machine reservoir. During CPB, 13 animals were given high MAP by norepinephrine (HP) while 9 animals had low MAP by nitroprussid (LP-N) and 8 animals had low MAP by phentolamine (LP-P). Fluid balance, hemodynamics, serum albumin (g/l) and plasmavolumes (CO-methode) (PV, ml/kg) were measured. Fluid extravasation rate (FER, ml/kg/min) was calculated. Statistical analysis by repeated measurements analysis with posttests (SPSS 13) Results as mean (SD). Results: ***: P Ͻ 0.001 compared with the other groups, same time. *: P Ͻ 0.05 compared with the LP-P, same time. Only statistics for between group differences are included. Conclusion: In this model, different MAP did not have a significant impact on fluid extravasation during CPB.

European Journal of Anaesthesiology, 2004

European Journal of Anaesthesiology, 2006

Tranexamic acid (TA) reduces blood loss in coronary artery surgery with cardiopulmonary bypass. T... more Tranexamic acid (TA) reduces blood loss in coronary artery surgery with cardiopulmonary bypass. The present prospective study was designed to investigate its hemostatic effect in off-pump coronary artery bypass (OPCAB). Seventy-six patients undergoing elective OPCAB were randomized into two groups, received TA (0.75 g loading dose before surgery and 250 mg/h during surgery, gross dose: 1.5 g, n=36) and saline solution (control, n=40), respectively. Perioperative blood samples were collected. Hematochemical parameters including platelet adhesion rate, D-dimer and fibrinopeptide-A (FPA) were analysis. Volume of blood loss, blood transfusion and other clinical data were recorded throughout the perioperative period. Cumulative blood loss was significantly reduced in the TA group as compared to the controls postoperatively (6 hrs (median [25th-75th]): TA: 200.0 [140.0-230.0] ml, 225.0 [200.0-347.5.0] ml, p=0.009; 24 hrs: TA: 440.0 [270.0-605.0] ml, 655.0 [500.0-920.0] ml, p<0.001). Number of patients received blood transfusion in each group was similar. Levels of D-dimer rose significantly after surgery, and were significantly lower in the TA group than that in controls. Platelet adhesion rate and FPA levels remained at baseline levels after the operation in two groups. Early clinical outcomes were similar between groups. The results indicated that tranexamic acid limits fibrinolysis and reduces blood loss after off-pump coronary artery bypass surgery.

Journal of Cardiac Surgery, 2008

Journal of Thoracic Disease, 2020

PloS one, 2018

The aim of the study was to analyse the presence of several metabolites related to atherosclerosi... more The aim of the study was to analyse the presence of several metabolites related to atherosclerosis in the plasma of patients with unstable carotid plaque and in the plasma of healthy subjects. We included 20 patients who had undergone carotid endarterectomy and 20 healthy subjects as a control group. All the subjects recruited were male. We used a metabolomic approach with liquid chromatography coupled to mass spectrometry to evaluate plasma metabolite levels in the metabolic pathway involved in the progression of atherosclerotic plaque. We observed that circulating levels of 20-HETE were significantly higher in patients with atheroma plaque than in healthy subjects (p = 0.018). No differences were found with regard to the other metabolites analysed. We also conducted a random forest analysis and found that 20-HETE was the main differentiator in the list of selected metabolites. In addition, plasma levels of 20-HETE correlated positively with body mass index (r = 0.427, p = 0.007) a...

Revista espanola de cardiologia (English ed.), Jan 17, 2017

Current postoperative management of adult cardiac surgery often comprises transfer from the inten... more Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus corona...

Revista Española de Cardiología (English Edition), 2017

A 45-year-old man with Crohn disease was referred for colectomy. Preoperative chest X-ray showed ... more A 45-year-old man with Crohn disease was referred for colectomy. Preoperative chest X-ray showed a right pulmonary hilum nodular image that prompted a thoracic computed tomography scan. Incidentally, a round mass was detected in the main pulmonary artery (Figure A, asterisk) and was further confirmed on computed tomography-angiography (Figure B-C; arrows; PA, pulmonary artery; RV, right ventricle). The patient denied prior chest pain, palpitations, dyspnea, or fever. Transthoracic and transesophageal echocardiography identified a round mass attached to the arterial side of the pulmonary valve, with no valve regurgitation. A magnetic resonance scan confirmed the presence of a 12-mm diameter mobile mass attached to the pulmonary valve, which was isointense on T 1-weighted images, highly hyperintense on T 2 , and was not perfused but was enhanced 10 minutes after gadolinium administration (Figure D-G, arrows; Video 1 of the supplementary material). Thus, the differential diagnosis between pulmonary valve papillary fibroelastoma and myxoma was established. Cardiac surgery was performed 1 month after colectomy. A well-defined round mucinous mass attached to the tip of the pulmonary valve was easily excised, with valve sparing (Figure H; Video 2 of the supplementary material). It consisted of an elongated and branching papillary proliferation covered by a single layer of cells (Figure I) on hematoxylin-eosin stain, which expressed endothelial cell markers (Figure J) on immunohistochemistry for erythroblast transformation-related gene, thus allowing diagnosis of papillary fibroelastoma. Papillary fibroelastomas are common, but not in a pulmonary position. The differential diagnosis with myxoma can be difficult, mainly if the masses are round-shaped. Magnetic resonance findings facilitate the diagnosis of a wide range of masses.