Papillary fibroelastoma as a rare cause of recurrent strokes and myocardial infarction

A 40-year-old male patient after two ischemic strokes was referred to our outpatient cardiac center for extended assessment.Previous evaluation revealed no significant causes of stroke. It excluded proximal atherosclerosis, arteritis, arterial dissection or atrial fibrillation (AF).Transthoracic echocardiogram demonstrated no intraventricular thrombus, valvular or regional wall motion dysfunction.Thrombophilia testing was negative: checked for lupus anticoagulant, anticardiolipin antibodies, anti-β2 glycoprotein I antibodies, antithrombin deficiency, protein C or S deficiency, factor V Leiden, prothrombin 20210 mutation, hyperhomocysteinaemia.Screening for connective tissue disease revealed no inflammatory markers elevation, presence of ANA, cANCA or proteinogram abnormalities.Cancer of other organs and infection were excluded.Apart from mildly elevated troponin concentrations in the acute peri-stroke period, patient's blood tests were normal.ECG showed sinus bradycardia and non-specific ST-T changes in the inferior leads.To search for a minor-risk cardioembolic sources we performed transesophageal echocardiography (TEE), which revealed neither cardiac thrombi, nor patent foramen ovale.It demonstrated a small, mobile, pedunculated mass arising from the anterior mitral leaflet (A1 segment), with maximum size of 4 mm (figure 1A), concerning for differential diagnosis of infective endocarditis, myxoma or papillary fibroelastoma (PFE).Patient was assessed as eligible for surgery.Coronary computed tomography angiography (CCTA) showed normal