Abstract | November 16, 2023
Rare Case of Cardiac Fibroelastoma- Cause of Embolic Strokes
Learning Objectives
- This case shows that we should consider cardiac papillary fibroelastoma (PFE) in the differential diagnosis while evaluating for cardioembolic stroke. The role of antiplatelet and anticoagulation is not clear in PFE, and further studies are needed to establish this.
- Study done by Tamin SS et al1 showed that PFE is the most common benign cardiac neoplasm of adulthood. This finding could be due to increasing use of echocardiography, better technology with improved resolution, enhanced awareness of PFE, and an aging population.
- Study by Tamin SS et al1 recommend that patients who are good surgical candidates (Society of Thoracic Surgeons score <1%) with left sided PFE (regardless of size, mobility, or location), surgical excision should be considered.
Introduction
We are presenting a case of embolic stroke due to papillary fibroelastoma of aortic valve.
Case Presentation
73-year-old female with past medical history of DM, hypertension, septic arthritis right knee (around 2 months back) and gout came with history of found unconscious by her daughter for unknown duration one day back. The patient was taken to a nearby hospital where CT head showed multifocal areas of hypodensity throughout both cerebral hemispheres and cerebellum suggestive of subacute embolic infarcts. She was referred to our hospital. At our hospital, on presentation, BP was 180/82 mm Hg. On examination, the patient was drowsy but followed commands. The neurological examination was significant for power 4/5 in right upper extremity and left lower extremity and 2/5 in left upper extremity and right lower extremity which was limited by pain in left shoulder and right knee. She developed a fever of 104.1 F. DD included cardioembolic stroke vs septic cerebral emboli for which workup was initiated. MRI brain showed multifocal bilateral cerebral and cerebellar acute infarcts with associated petechial hemorrhage, mild enhancement of bilateral parietal infarcts. CTA head showed 60% proximal right ICA stenosis and 40% proximal left ICA stenosis. Blood cultures were negative.
Final diagnosis
TTE was unremarkable so TEE was done which showed normal LV systolic function, no ASD, no VSD, no PFO, EF 55 to 60%, no evidence of vegetation, no intracardiac clot, but it showed that aortic leaflet left coronary cusps has suspicious fibroelastoma.
Management
The patient underwent exploratory cardiotomy and excision of aortic valve mass. Pathological report of the excised mass showed benign papillary fibroelastoma, tumor of aortic valve. Patient’s post-operative period was complicated by right lung atelectasis, right sided pleural effusion, hypoxic respiratory failure, AKI and new onset paroxysmal AF. The patient was eventually discharged to the rehabilitation center on aspirin and statin. Anticoagulation was not given on discharge as new onset AF developed in the post-operative period. This is a very interesting case as while evaluating embolic stroke and fever, we did TEE which showed papillary fibroelastoma, a rare finding which was the cause of the embolic stroke.
References and Resources
- Tamin S.S., Maleszewski J.J., Scott C.G., Khan S.K. et al. Prognostic and bioepidemiologic implications of papillary fibroelastomas. J Am Coll Cardiol. 2015 Jun 9;65(22):2420-9.
