VERY MOBILE LEFT VENTRICULAR PAPILLARY FIBROELASTOMA PRESENTING WITH ISCHEMIC STROKE

Papillary fibroelastomas are small and pedunculated left side valves associated mass, that frequently causing cerebral embolization; they are composed of collagen and elastic fibers and are usually connected with a pedicle to the endocardial layer. Differential diagnosis with endocarditis can rely on the side of attachement: Papillary fibroelastomas are more frequently found downstream the valves, instead, endocarditis are mostly found upstream the valves. They are mostly located (>80%) on valvular surfaces, more commonly on left side cardiac valves (44% on the aortic valve and 35% on the mitral valve); therefore, in the present knowledge, papillary fibroelastomas arising from left ventricular myiocardial wall are rare and mostly anecdotally descripted. We present the case of a 78–year–old man, diabetic, with no cardiac history, hospitalized with a right capsulo–lenticular stroke. Symptomatic due to left hemiparesis, he did not undergo thrombolysis due to a delay in hospitalization of almost 24 hours. The transthoracic and then transesophageal echocardiogram showed the presence of a hyperechogenic, floating mass of approximately 3 cm at the level of the left ventricle, separate from the mitral valve and attached to the mid–distal anterior septum and the ventricular apex (Figure 1). Cardiac MRI confirmed the presence of a peduncolate left ventricular mass, isointense on cine sequences, without myocardial infiltration, isointense on T1–weighted images and mildy hyperintense on T2–weighted images, with mild uniform late–gadolinium enhancement (Figure 2). The patient underwent surgical removal of the mass: histological analysis showed multiple, branching fronds of paucicellular, avascular fibroelastic tissue lined by a single layer of endocardium, with positive stains at Weigert coloration for elastic fibers (Figure 3). Histomorphological analysis was compatible with papillary fibroelastoma. This is a very atypical case of papillary fibroelastoma, due to the large size of the mass and the intraventricular and not–valvular location, which determined its emboligenicity and which, if not removed, would have exposed the patient to an enormous risk of recurrence of stroke.