Multiple Papillary Fibroelastomas and Thrombus in the Left Heart
A 68-year-old male with hypertension and atrial fibrillation, was admitted with progressive worsening dyspnea and chest pain. Physical examination at the time of the first admission revealed a temperature of 36.5℃; respiration 20/min; pulse, 100/min and irregular; and blood pressure, 120/80 mmHg. There was a prolonged diastolic murmur at the apex and laboratory data were unremarkable. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. A chest X-ray showed cardiomegaly. TTE revealed a large left atrium of 7.22 cm diameter, severe mitral stenosis, mild mitral regurgitation, moderate aortic regurgitation, and presence of a multiple oscillating variable sized masses in the left ventricle and aortic valve, non-mobile 3.5 × 4.4 cm sized mass in the left atrium. The mitral valve leaflets were heavily thickened and calcified. The masses in the left ventricle were 0.31 × 0.92 cm, and 0.54 × 0.98 cm in size, oscillating heterogeneous echogenic material attached to the interventricular septum basal to mid level and 1.46 × 1.64 cm, 0.47 × 1.07 cm in size, mobile oval shaped mass, which had some echolucent area attached to the posterolateral papillary muscle and aortic valve (). The mass of the left atrium was 3.5 × 4.4 cm in size, non-mobile echogenic mass in the left atrium posterior wall. Cardiac magnetic resonance imaging demonstrated non-enhanced masses in the left atrium between the orifice of the right superior and inferior pulmonary vein and ventricle, which were heterogeneous in its signal intensity in T2 image (). Coronary angiography was normal. Based upon the findings as above, a differential diagnosis was made, which included thrombus, myxoma, fibroelastoma and inflammatory mass. In view of the possibility of embolism, unknown nature of the pathology and multiple valve diseases with symptoms, the patient was taken for urgent surgical resection with valve replacements.\nHistopathology examination of the resected masses in the left ventricle and aortic valve revealed a papillary proliferation, including an avascular connective tissue core lined by a single layer of the endothelial cells, which was sufficient for a diagnosis of CPF (). The left atrial mass was composed of fibrin and red cells with a variable platelet and leukocyte component, revealed to thrombus.\nThe postoperative course was uncomplicated and the patient was discharged in a satisfactory condition on the 12th day.