273 A Curative Cause for Recurrent Embolic Ischaemic Events

Abstract

This case report describes a patient with recurrent ischaemic events, the cause of which is unusual and rare. A thorough evaluation and high index of suspicion are required as diagnosis is management altering and provides good long-term prognosis. A 51-year-old lady presented with a ST-elevation myocardial infarction. This was her third acute ischaemic event following a previous NSTEMI and ischaemic stroke. ECG showed ST-segment elevation in leads I and aVL and emergent angiography was undertaken. This showed acute occlusion of the mid-distal 3rd diagonal artery. There remained an occlusion of the distal OM1 artery (previous event), and the rest of her coronary arteries were unchanged from previous. She was treated medically and underwent echocardiograph. This revealed nodular thickening of the anterior mitral valve leaflet with a 6mm x 6mm mass. Transoesophageal echocardiograph confirmed this lesion on the A2 scallop of the mitral valve, with the lesion measuring 9mm x 7mm. The patient underwent surgical resection and a Mosaic bioprosthetic 29mm mitral valve replacement was implanted. Histological examination of the lesion revealed it to be a papillary fibroelastoma. Papillary fibroelastomas are the third most common form of ‘benign’ cardiac tumour and have been shown to cause myocardial infarction, stroke and pulmonary emboli. Patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) should undergo evaluation for potential causes including spontaneous coronary artery dissection, paradoxical emboli, coronary spasm and coronary embolisation. In this case, the patient’s management was altered, and she has been spared from further events.