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Heart. 2007 May; 93(5): 590.
PMCID: PMC1955536

Papillary fibroelastoma in the left ventricular outflow tract

A 78‐year‐old man presented with a short history of severe dyspnoea and bradycardia (2:1 heart block, 30 bpm). Examination showed an ejection systolic murmur, and echocardiography showed a heavily calcified aortic valve with a peak gradient of 90 mm Hg. A large mobile mass (1.2×1.5 cm) was also observed in the region of the left ventricular outflow tract (panel A). Angiography was then undertaken, which showed coronary artery disease in the left anterior descending artery and the first obtuse marginal artery. At aortotomy, a heavily calcified stenotic bicuspid aortic valve was excised to disclose a large mobile 1.0×1.5 cm pedunculated mass at the junction of the membranous and muscular septum. A bioprosthetic aortic valve (23 mm Perimount, CE Lifesciences, Woodridge, Illinois, USA) and coronary artery bypass grafts were performed. Histological examination of the mass showed it to be a papillary fibroelastoma (panels B,C). Papillary fibroelastomas are benign tumours that usually arise from valvular endocardium. They account for 8% of all cardiac tumours; however, as the incidence of primary cardiac tumours is low, at 0.002–0.33%, papillary fibroelastoma is correspondingly very rare. They can cause significant disease owing to their tendency to obstruct blood flow or embolise, and therefore should be surgically removed when found in the left side of the heart. This case is particularly interesting as it presented due to involvement of the conduction system, resulting in 2:1 heart block. To date, it seems to be the only papillary fibroelastoma of the left ventricular outflow tract to present with abnormalities of the conduction pathway.

figure ht93013.f1
(A) Transthoracic echocardiogram showing a well‐circumscribed pedunculated tumour (white arrow) along the outflow tract of the left ventricle. (B) Gross picture of the resected left ventricular outflow papillary fibroelastoma showing fine papillary ...

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