A mobile aortic valve mass in a patient with multiterritorial ischemia

Background: Papillary fibroelastoma is a benign cardiac tumor that most often arises from the valves. Although usually small, a mobile left-sided lesion can be clinically important because of its embolic potential. Case Presentation: A 73-year-old woman with no major cardiovascular risk factors other than age was referred after an ischemic stroke of undetermined origin. Brain imaging had shown bilateral thalamic infarction. Imaging of the supra-aortic vessels was unremarkable, and both 24-hour and prolonged rhythm monitoring showed no atrial fibrillation. Her history was also notable for a separate episode of acute intestinal ischemia requiring emergency surgery. At laparotomy, ~150 cm of necrotic small bowel was found. No adhesive band was identified, and the necrotic segment was resected. Because the cerebral event remained unexplained, transesophageal echocardiography was performed. It demonstrated a solitary, irregular, highly mobile mass measuring about 8 mm near the commissure between the noncoronary and left coronary cusps of the aortic valve (Figure 1). The valve was otherwise structurally preserved, without significant stenosis or regurgitation. No left atrial appendage thrombus or patent foramen ovale was seen. Repeated transthoracic echocardiograms had not clearly visualized the lesion. Two- and three-dimensional transesophageal imaging better defined its mobility, morphology, and site of attachment. Surgical excision of the aortic valve mass is planned but has not yet been performed. Consequently, histopathological confirmation is not available. Discussion: The echocardiographic appearance was strongly suggestive of papillary fibroelastoma. These tumors are recognized potential sources of systemic embolism, particularly when they are left-sided and mobile [1,2]. Mesenteric ischemia has also been reported among the embolic presentations of valvular papillary fibroelastoma [3]. In this patient, however, neither the cerebral nor the intestinal event can be attributed to the valve mass with certainty. No embolus was directly demonstrated in the mesenteric vessels, and histologic confirmation of the cardiac lesion was not available at the time of this report. Differential diagnoses included thrombus, vegetation, and Lambl’s excrescences; however, the solitary, irregular, highly mobile appearance and the clinical context favored papillary fibroelastoma. Conclusion: This case illustrates how a small valvular mass may remain inconspicuous on transthoracic imaging despite marked mobility. In patients with otherwise unexplained ischemic events, transesophageal echocardiography can reveal a clinically relevant potential embolic source and provide more precise characterization of small valve lesions.