Case of the Month #174: Papillary Fibroelastoma of the Aortic Valve

Abstract

A 53-year-old woman with a history of mitral valve prolapse and hyperthyroidism presented to the emergency department with nonradiating chest pain (‘‘pins and needles in the heart’’). She also had worsening shortness of breath on exertion and weakness and weight loss over a 3-month period. On physical examination, her heart rate was 110 beats per minute and respiratory rate was 18 per minute. Cardiac auscultation revealed a late systolic murmur over the mitral area that radiated to the axilla. Pulmonary examination was normal. Transthoracic echocardiography showed a mitral valve prolapse, withmild regurgitation. It also revealed a 9 10-mm mass on the left coronary cusp of the aortic valve. Transesophageal echocardiography (Figure 1) showed the mobile pediculated mass attached to the base of the aortic surface of the left coronary cusp of the aortic valve as well as thickening of the cusp. Anterior leaflet prolapse of the mitral valve with moderate regurgitation also was demonstrated. Cardiac magnetic resonance (MR) imaging quantified the prolapse of the mitral valve as moderate. The aortic valve lesion, however, was poorly visualized. An electrocardiographic (ECG) gated contrast-enhanced cardiac computed tomography (CT), performed for preoperative assessment of the coronary arteries, allowed visualization of a 8-mm aortic valvular lesion, on the aortic surface of the valve (Figure 2). Surgery revealed the lesion of the aortic valve located on the