Papillary Fibroelastoma Mimicking Vegetation of the Mitral Valve
A 51-year-old man had been admitted to a regional hospital for treatment of avascular necrosis of the femoral head where he received antibiotics for 2 weeks to treat a suspicious vegetation apparent on TTE. Because the size of the cardiac mass had not changed, the patient was referred to our hospital for further evaluation.\nOn physical examination, his blood pressure was 110/70 mmHg, pulse rate 65/min, respiration rate was 21/minute, and body temperature was 36.7℃. Heart sounds were regular without cardiac murmurs. Both lungs expanded symmetrically, and breath sounds were clear. The laboratory findings were as follows: hemoglobin, 14.6 g/dL; total leukocyte count, 9730/mm3 (neutrophils, 59%); platelet count, 251000/mm3; and erythrocyte sedimentation rate, 23 mm/hr. Results of urinalysis, blood chemistry, and electrolyte tests were within normal ranges. An electrocardiogram revealed normal sinus rhythm. Chest X-ray was normal, as was TTE except for a mass on the mitral valve. The mass was 1.0 cm in size, mobile, attached to anterior mitral leaflet, and round with a homogenously speckled surface (). There was no mitral regurgitation, stenosis or intracardiac shunt. Although the findings of TTE look like vegetation, the laboratory results did not show any evidence of infection and no signs or symptoms of infective endocarditis including Janeway lesion, Osler nodes, and conjunctival hemorrhage were detected in physical examination. Additionally no organisms were cultured in repeated microbiologic studies. Thus, the clinical and echocardiographic findings may represent cardiac tumor such as papillary fibroelastoma rather than vegetation or thrombus.\nThe cardiac mass was removed by surgery in order to reduce the risk of embolism for PFE as well as to rule out the infective endocarditis. Under standard cardiopulmonary bypass, the left atrium was opened vertically from the right side. On exploration, a 1.2 × 1.0 cm pedunculated mass was found on the anterior mitral leaflet. On gross examination, the mass was soft, slippery, and had numerous filaments (). The mass was removed using a shave excision technique. However, there was significant mitral regurgitation after mass excision and following excision of the mitral leaflets and chordae, a mechanical valve was implanted. Histopathology confirmed that it was a benign PFE, comprising a central a vascular collagenous core of dense connective tissue surrounded by a peripheral layer of loose connective tissue. The papillary surface was covered by a layer of endothelial cells and had fibrous stroma, including elastic fibers (). The postoperative course was uneventful and the patient was discharged in a satisfactory condition on the seventh day.