the incidence of primary cardiac tumors is low , at 0.001% to 0.03% [ 1 - 3 ] .
the advent of variable cardiac imaging modalities , including echocardiography and multidetector computed tomography ( ct ) , has led to the identification of an increasing number of cases of asymptomatic cardiac tumors .
cardiac papillary fibroelastoma ( cpf ) is a rare and benign cardiac tumor that can arise anywhere in the heart , but usually involves cardiac valves .
moreover , the incidence of cpf in the left ventricle is lower than that in other parts of the heart .
here we report a case of left ventricular cpf detected by echocardiography and successfully surgically resected .
a 65-year - old woman was referred to our cardiology department for evaluation of a cardiac mass of the left ventricle .
prior to the referral , she was admitted to another hospital with a complaint of chest pain of 3 days ' duration . coronary angiography and echocardiography
coronary angiography showed no significant coronary disease , but a mass was found by echocardiography .
she had been treated for hypertension and a stroke she suffered 5 years prior . on physical examination , her blood pressure was 110/70 mmhg , and her pulse rate was 62 beats / min .
transthoracic echocardiography revealed a 1.8  1.7 cm highly mobile round mass attached by a stalk on the apical inferior wall of the left ventricle with an echolucent area ( fig .
ct of the chest showed a 1.9  1.6 cm round and pedunculated mass with soft tissue density on the apical inferior wall of the left ventricle ( fig .
on opening the left atrium , there was a mass attached deep to the inferior wall of the left ventricle .
the resected tumor was 1.8  1.5 cm and had the appearance of a sea anemone ( fig .
histology showed that the lesion had a papillary configuration with an avascular connective tissue core ( fig .
among primary cardiac neoplasms , benign tumors account for 63% and malignant tumors for 37% .
the mean age at diagnosis of cpf is approximately 60 years , although it has been reported in teenagers and children .
cpf affects both sexes , but males predominate in most series . in the study of a series at the mayo clinic from 1957 to 2001 , of 110 primary cardiac tumors that were surgically removed
a recent study reported that cpf represented 5% of primary cardiac tumors in 21 patients . in a report of 110 cpf cases ,
about 90% of cpfs appeared on cardiac valves , and the remainder originated from nearly all portions of the non - valvular endocardium , including the left ventricular septum , the left ventricular mural endocardium , the right ventricular outflow tract , the right atrium , the atrial septum , the papillary muscle , the chordate tendinea , the eustachian valve , and the chiari network .
they have a gelatinous membrane on the surface and a stalk with multiple papillary projections .
microscopically , cpfs are composed of a central stalk with radiating villus - like projections .
the papillae are avascular structures , containing a core of dense collagen fibers admixed with varying amounts of reticulin and elastin fibers .
the microscopic structure of a cpf closely resembles that of chordea tendineae , which prompted some to propose a hamartomatous - like pathogenesis .
a cpf is a collection of avascular fronds of dense connective tissue lined by endothelium .
however , it is deemed to be a reactive process rather than a true neoplasm .
it is suggested that cpf may be associated with lambl 's excrescence and shear stress , and congenital factors may be involved in its development ; however , the cause remains unclear . with improved echocardiographic resolution due to higher transducers and new imaging modalities ,
cpf was considered to be an incidental autopsy finding and to have no clinical significance in the past .
the clinical presentation of a cardiac tumor is determined by its location , size , and mobility .
in particular , left - sided , larger sized (  1 cm ) and highly mobile tumors have a higher incidence of embolization .
cpfs have a predilection for the left side of the heart . in a review of the literature regarding complications in 79 cases of cpf
, 61 lesions occurred on the left side of the heart , whereas only 18 were right - sided .
cpfs are generally slow growing tumors , but may serve as nidi , allowing formation of large superimposed thrombi over a short period of time .
symptoms include cerebral infarction and transient cerebral ischemic attack associated with soft and fragile fibroelastoma in 44% of patients , angina pectoris in 18% , myocardial infarction in 10% , cardiac failure in 9% , and sudden death in 8% .
symptomatic cpf should be resected surgically ; however , there are no guidelines for the treatment of asymptomatic cpf .
large , left - sided mobile tumors should be excised to prevent sudden death and emboli .
small , non - mobile tumors may be followed with serial echocardiography and removed if they increase in size or become mobile or symptomatic .
various methods have been proposed for complete excision of left - sided cpfs to avoid a left ventriculotomy due to further complications . for tumors deep within the left ventricular cavity close to the apex , the use of a cardioscope passing through the aortic or mitral valve is recommended to avoid damage to the valvular apparatus . in our case
, we used a surgical approach through the left atrium and mildly pushed up the left ventricular apical inferior wall for easy resection of the mass .
recently , a case in which a cpf deep in the left ventricle was resected under the guidance of a gastrointestinal fiberscope was reported . in this report
, we present a case of cpf attached to the left ventricular apical inferior wall , which was successfully removed surgically .
 cardiac papillary fibroelastoma ( cpf ) is a rare and benign primary cardiac neoplasm of unknown prevalence . 
 the incidence of cpf in the left ventricle is lower than that in other parts of the heart . 
 a 65-year - old female was referred to our cardiology department for evaluation of a cardiac mass of the left ventricle . 
 transthoracic echocardiography revealed a 1.8  1.7 cm highly mobile round mass attached by a stalk to the apical inferior wall of the left ventricle with an echolucent area . 
 the mass was successfully removed without any postoperative complications and was identified as a cpf . 