Papillary fibroelastoma of the left heart with multiple origins?

We appreciate the excellent report of Rolf et al. on a papillary fibroelastoma of the ascending aorta causing myocardial infarction via right coronary artery (RCA) occlusion in a 78-year-old patient [1]. Papillary fibroelastomas are indeed the most common heart valve tumors with equal frequencies on the semilunar and atrioventricular valves of the left heart (in 95% of cases). However, papillary fibroelastomas that originate from the aortic wall are considered to be very rare. In 2009 we reported on a patient with an aortic wall fibroelastoma that was located directly next to the right coronary ostium on imaging studies. This patient had a history of instable angina pectoris and embolic stroke with recurrent dizziness. Intraoperatively, the tumor was found to, in fact, originate from the aortic wall and partially obstruct the right coronary ostium. The formation was successfully removed and current follow-up two years postoperatively revealed a stable and uneventful postoperative course [2]. In the case of Rolf et al. the tumor was reported to be located at the distal portion of the ascending aorta, quite far away from the aortic sinuses. Therefore, retrograde coronary embolization of this small, high-sitting tumor is an interesting occurrence. Whether a different second localization of the tumor within the left ventricular structures or on the aortic valve with subsequent embolization caused myocardial infarction preoperatively remains debatable. Such constellation may possibly explain the postoperative occurrence of transient neurological deficits, which can be attributed to mobilization of a lesion of undetected localization. In conclusion, regardless of whether being a random diagnosis or coming along with embolic events and/or valve dysfunction, papillary fibroelastomas of the aortic wall require urgent surgical removal due to the risk of lifethreatening complications.