An atypical cause of myocardial infarction: case report of an obstructing papillary fibroelastoma of the aortic valve

Rheumatic heart disease of the mitral valve alongside the papillary fibroelastoma of the aortic valve: A case report

Key Clinical Message

Besides thromboses, it's crucial to also consider the rare possibility of tumors like papillary fibroelastomas when evaluating worsening cardiopulmonary symptoms in patients with severe rheumatic mitral stenosis and atrial fibrillation.

Abstract

Cardiac papillary fibroelastoma is a rare and benign endocardial tumor typically found on the aortic valve. The simultaneous occurrence of rheumatic heart disease affecting the mitral valve and papillary fibroelastoma on the aortic valve is infrequent, with limited documented instances. This unique case can enhance our understanding of the clinical presentation, diagnostic approaches, management options, and implications for patient outcomes in these two conditions. We present the case of a 47-year-old woman who was admitted to the hospital due to worsening dyspnea and fatigue, during which time she discovered an aortic valve papillary fibroelastoma. Further investigations revealed two thrombi in her left atrium and left atrial appendage, along with significant rheumatic mitral valve stenosis. The patient underwent thrombectomy, mitral valve replacement, and valve-sparing aortic valve tumor resection. Following surgery, the patient's recovery was unremarkable. This case report emphasizes the need for a comprehensive evaluation in patients with rheumatic mitral stenosis, considering all possible etiologies. While thrombi are typical in mitral stenosis and atrial fibrillation, the rare presence of tumors like papillary fibroelastomas should be recognized, underscoring the importance of further assessment when suspicion arises. Importantly, individuals with asymptomatic cardiac papillary fibroelastomas should undergo surgical treatment to minimize the potential risk of tumoral embolization.

Successful interdisciplinary treatment of a rare cause of acute myocardial ischaemia from intermittent tumour-associated obstruction of the left main coronary artery: a case report

Background

A papillary fibroelastoma of the aortic valve has been reported as a rare cause of myocardial ischaemia. An advanced combined interventional and surgical approach leading to sufficient therapy for the patient is presented in this case report.

Case summary

A 56-year-old female patient presented in an emergency room of a hospital with an acute coronary syndrome. Over 1.5 years, recurrent stable angina had been known in the patient and significant coronary artery disease has already been ruled out in a previous coronary angiogram. The patient was immediately transferred to the catheter laboratory due to cardiogenic shock where a drug-eluting stent was implanted to, firstly, recanalize the left main coronary artery (LMCA) and, secondly, to protect the left main ostium from obstruction by an echocardiographic-proven mass. During subsequent deterioration of haemodynamics caused by decreasing left ventricular function and acute severe mitral insufficiency, firstly an intra-aortic balloon pump and secondly a veno-arterial extracorporeal membrane oxygenation was established through the femoral vessels. The patient was transferred to our cardiac surgery unit and was successfully operated utilizing a valve-sparing technique by extracting the tumour mass from the left coronary cusp and extracting the stent carefully from the LMCA. Histology revealed a papillary fibroelastoma.

Conclusion

A papillary fibroelastoma of the aortic valve with intermittent obstruction of the coronary arteries requires surgical therapy. Interventional recanalization and extracorporeal support might be useful strategies to ensure the patient’s safety as a bridge to surgery.