Abstract
Papillary fibroelastomas (PFE) are reported to be the most common tumors of the heart valves and are a possible source of systemic embolism, including myocardial infarction.
We report the case of a 67-year-old female with no background of cardiovascular disease, admitted to our hospital with worsening dyspnea and chest tightness over the prior 10 days.
The ECG showed a sustained hemodynamically tolerated monomorphic ventricular tachycardia, successfully treated with antiarrhythmic therapy, and ECG in sinus rhythm revealed signs of previous anterior myocardial infarction. Transthoracic echocardiogram showed a severely depressed systolic function (LVEF 19%), akinesia and thinning of the anterior wall and of all middle-apical segments, complicated by left ventricular aneurysm and endoventricular thrombosis. In the ventricular side of right aortic coronary cusp a mobile, pedunculated mass of 12×8 mm was visualized. A subsequent TEE corroborated the suspicion of PFE. She underwent cardiac MRI which showed areas of transmural late enhancement in all akinetic segments. A coronary angiography revealed sub-occlusion of the mid-anterior descending artery with no angiographic evidence of coronary atherosclerosis elsewhere. In view of her reduced LVEF and history of VT, an ICD was implanted. She started oral anticoagulant therapy and complete resolution of the endoventricular thrombosis was evidenced. After several days of electrical instability, characterized by multiple episodes of ventricular tachycardia, the clinical course was characterized by progressive clinical and electrical improvement and she was discharged in good clinical conditions after four weeks. Due to the severe impairment of the systolic function, not susceptible to surgical remodeling and the high operative risk, no indication for surgical removal of the mass was made.
Aortic PFE carry a not negligible risk of acute coronary syndrome, electrical storm and sudden death. It should be considered as the cause of myocardial infarction, and not an incidental finding, especially in patients with no angiographic evidence of coronary atherosclerosis.
