May 5, 2019European Heart Journal - Case ReportsOpen Access

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

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Why the study?

Papillary fibroelastomas are rare primary cardiac tumours that confer an increased risk of thrombo-embolism, but direct coronary ostial obstruction is an unusual cause of myocardial infarction.

Structured PICO

Population

A 54-year-old woman presenting with central chest pain radiating to her left arm and elevated troponin (n=1).

Intervention

Echocardiography and shave excision of the lesion.

Outcome

Diagnosis and surgical management of the cause of myocardial infarction.

This case demonstrates that papillary fibroelastomas can cause myocardial infarction through direct mechanical obstruction of the coronary ostium, rather than just thrombo-embolism.

Implication

Raises awareness of mechanical coronary occlusion by fibroelastoma in MI; case report leaves open its true incidence.

Abstract

BACKGROUND: Papillary fibroelastomas are rare primary cardiac tumours with a prevalence of 0.01% at autopsy. They are histologically benign tumours but have been demonstrated through case series to confer an increased risk of thrombo-embolism resulting in: transient ischaemic attack, stroke, myocardial infarction, and pulmonary and systemic embolization. CASE SUMMARY: A 54-year-old woman presented with central chest pain radiating to her left arm. At presentation there was a significant troponin rise; initial high-sensitivity troponin-I (hsTn-I) 660 pg/mL increased to 3340 pg/mL at 6 h. Coronary angiogram did not reveal any obstructing coronary artery disease. Echocardiography revealed a rounded, mobile mass on the left coronary cusp of the aortic valve suspicious for papillary fibroelastoma. The patient underwent shave excision of the lesion. Intra-operatively it was noted that the mass intermittently sat within the ostium of the left main resulting in its occlusion. Histology confirmed a papillary fibroelastoma. DISCUSSION: Primary cardiac tumours are rare but can cause life-threatening complications such as stroke, myocardial infarction, and cardiac arrest. In the literature, the mechanism of these complications is mainly attributed to thrombo-embolism. This case demonstrates the utility of echocardiogram in investigating and diagnosing a rare cause of myocardial infarction and highlights an unusual mechanism, that is tumour causing obstruction of the coronary ostium.