A Large Cardiac Papillary Fibroelastoma Arising from the Coumadin Ridge: Unusual Location and Presentation

Figure 1. Serial TTE (3 months apart). (A) Apical five-chamber view demonstrates the absence of a cardiac mass within the left atrium (asterisk). (B) Three months later, a similar apical five-chamber view demonstrates the presence of a moderate-sized cardiac mass within the LA chamber (asterisk).

Figure 2. TEE. (A) Midesophageal four-chamber view at 0° with biplane orthogonal 90° view (B) focusing on a 2.3 × 2.0–cm, globular, heterogeneous, pedunculated mass (arrow), which appears attached to the limbus of the LA appendage, also known as the coumadin ridge.

Figure 3. TEE. (A,B) Midesophageal view at 0° showing the PFE (arrow) within the left atrium attached to the tip of the limbus of the LA appendage, also known as the coumadin ridge, and demonstrating the spatial relationship between the PFE (arrow), the limbus (asterisk), and the left upper pulmonary vein (LUPV).

Figure 4. Three-dimensional TEE demonstrating the location of the PFE (arrow) as it arises from the coumadin ridge (A,B), with the aortic valve at the top of the image (not visualized) and the LA appendage to the left of the coumadin ridge and the PFE. Note in a more distant plane the anterior leaflet of the mitral valve in (C) and the mitral annulus in (D).

Figure 5. Three-dimensional TEE demonstrating the inflow cannula position (arrow) after placement of a HeartMate II left ventricular assist device.

Figure 6. Gross and microphotograph of the excised mass. The gross specimen (left) was received fragmented, with the largest piece measuring 3.2 cm, showing pieces of branching papillary tumor with bulbous gelatinous fronds. On light microscopy (top right, Hematoxylin and Eosin; bottom right, Movat pentachrome, 400× magnification), the fronds showed a central core of fibrous tissue (yellow in the Movat stain). Each frond consisted of a mucopolysaccharide-rich stroma (green) lined by endothelial cells. The fibrous cores of some of the papillae contained elastic fibers (black), as demonstrated in the Movat stain.