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Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 169-171

Balloon angioplasty treatment in inferior acute coronary syndrome secondary to undiagnosed papillary fibroelastoma

Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai, UAE

Date of Submission18-Jan-2020
Date of Decision03-Mar-2020
Date of Acceptance29-Mar-2020
Date of Web Publication2-Sep-2020

Correspondence Address:
Omar Yousef Al-Assaf
Department of Cardiology, Rashid Hospital, Dubai Health Authority, Dubai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HMJ.HMJ_6_20

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A patient presented with typical cardiac chest pain on electrocardiogram (ECG) was found to have a ST-elevation myocardial infarction. Coronary angiography found normal coronary arteries; however, the symptoms and ECG findings were cause by an undiagnosed papillary fibroelastoma externally occluding the coronary artieries. Treatment was done via a balloon angioplasty and later by surgery.

Keywords: Coronary angiography, papillary fibroelastoma, ST-elevation myocardial infarction

How to cite this article:
Abbas AM, BinBrek AS, Benny SC, Al-Assaf OY. Balloon angioplasty treatment in inferior acute coronary syndrome secondary to undiagnosed papillary fibroelastoma. Hamdan Med J 2020;13:169-71

How to cite this URL:
Abbas AM, BinBrek AS, Benny SC, Al-Assaf OY. Balloon angioplasty treatment in inferior acute coronary syndrome secondary to undiagnosed papillary fibroelastoma. Hamdan Med J [serial online] 2020 [cited 2022 Jan 20];13:169-71. Available from: http://www.hamdanjournal.org/text.asp?2020/13/3/169/294177

  Introduction Top

Acute coronary syndrome (ACS) is considered the second leading cause of mortality following cancer, and in some countries, it is the leading cause of mortality. ACS is pathologically found to be mainly caused from plaque rupture and intracoronary thrombus formation. However, other less common causes can present as ACS including coronary vasospasm, coronary embolisation from infective endocarditis, aortic calcification and rarely from an aortic mass.[1] There are currently no guidelines specifically made to address such rare cases in relation to follow-up and antiplatelet therapy and its duration.

  Case Report Top

A 35-year-old male smoker presented to our hospital complaining of sudden severe typical cardiac chest pain that started while playing sport. The pain continued even after rest for 3 h till presentation to the Accident and Emergency (A and E).

On examination, he was haemodynamically stable, with a blood pressure of 142/94 mmHg, regular heart rate of 75 beat/min, temperature of 36.5°C, respiratory rate of 16 cycles/min and, on room air, an oxygen saturation of 100%. Cardiovascular physical examination was unremarkable.

Medical history

The patient is not known to be diabetic, hypertensive, having dyslipidaemia or having a previous ischaemic heart disease. Family history or drug history is unremarkable.

His initial electrocardiogram (ECG) showed sinus rhythm, minimal ST-elevation in the inferior leads with minimal reciprocal ST-depression in the lateral leads with Q wave in lead III, aVF. His initial cardiac troponin was 0.10 ng/ml, CK-MB 28 U/L and creatinine-phosphokinase 232 U/L, and the complete blood count showed white blood cell count of 20 000 cells/uL, haemoglobin level of 13.8 g/dL and platelets of 254 000 cells/uL. Other laboratory investigations were within normal ranges.

Serial ECGs confirmed ST-elevation in the inferior leads [Figure 1]. Subsequent cardiac enzymes confirmed acute myocardial infarction.
Figure 1: Electrocardiogram showing sinus rhythm, minimal ST elevation in inferior leads with minimal reciprocal ST depression in lateral leads with Q wave in lead III, aVF

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Dual-antiplatelet therapy with high-intensity statins was started, and the patient underwent percutaneous coronary intervention (PCI). His coronary angiogram exposed a very proximal subtotal right coronary artery (RCA) occlusion that looked like a thrombus with a normal left coronary artery [Figure 2]. During the procedure, the PCI wire easily passed through the RCA and an aspiration catheter failed to pass through the lesion. A 2.5 mm × 12 mm balloon passed the lesion and inflated to 10 atmospheric pressure. Rechecking of the films soon after withdrawing the balloon revealed normal RCA [Figure 3].
Figure 2: Coronary angiography showing proximal right coronary artery lesion

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Figure 3: Coronary angiography showing resolution of proximal right coronary artery lesion after balloon angioplasty

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The next day, the patient underwent transthoracic and trans-oesophageal echocardiography which showed an ejection fraction of 60%–65% with normal left ventricular and two echogenic masses seen near the right coronary cusp of the aortic valve. The largest mass was a freely moving strand measuring 2 cm in length at the aortic site of the valve with the tip hitting the right coronary sinus wall [Figure 4]. The other was a small 6 mm × 4 mm echo density just under the valve in the ventricular side, highly suggesting a papillary fibroelastoma.
Figure 4: Trans-oesophageal echocardiography shows elongated mass in the right coronary cusp of the aortic valve

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Few days later, the patient underwent removal of the aortic mass. The aortic valve was tri-leaflet healthy. Both right and left coronary ostia were free from any lesions or masses. A longitudinal whitish mass was found at the base of the right coronary cusp of the annulus measuring 15 mm × 20 mm. The mass was totally excised from the base which had calcification and sent for histopathology [Figure 5]. The biopsy results reported nodular fragment showing calcification, necrotic tissue and degenerative changes. There was no evidence of malignancy, suggesting the diagnosis of papillary fibroelastoma. He had an unremarkable postoperative recovery.
Figure 5: Gross appearance of two by 1.5 cm long mass surgically removed from the right cusp

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  Discussion Top

Primary cardiac tumour prevalence ranges from 0.0017% to 0.28%, and papillary fibroelastomas (PFEs) are found to be the second most common benign neoplasm of the cardiac valves after myxomas.[2],[3] These tumours are generally considered pathologically benign. However, due to outflow obstruction or embolism, PFE can present with multiple cardiac and non-cardiac symptoms and diseases; syncope, chest pain, heart attack, stroke and sudden cardiac death.[4]

PFE symptoms develop either due to mechanical compression effect of the mass or due to embolisation of a portion of the tumour to a distal organ.[5],[6] If the tumour was found incidentally in an asymptomatic person, the treatment approach is controversial. A conservative approach is warranted in certain individuals, but if the tumour is large and pedunculated surgical excision might be needed before symptom development.[7]

In this case report, the patient presented with ST-elevation in inferior leads, indicating an inferior myocardial infarction, and underwent primary PCI. The lesion which appeared to be like a thrombus disappeared completely after gentle inflation of the balloon and the RCA was normal. The next day, the echocardiography showed echogenic masses near the aortic valve in the right coronary cusp.

If echocardiography was done before primary PCI, then the ultimate approach will be coronary angiography followed by surgery in a timely matter. On the other hand, one would argue that gentle inflation of a balloon seems as a reasonable approach as we have demonstrated in our case. Finally, there is always the danger of breaking the mass and causing embolisation. Hence, an interventional radiologist is recommended to be available throughout the treatment.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.  Back to cited text no. 1
Baikoussis NG, Papakonstantinou NA, Dedeilias P, Argiriou M, Apostolakis E, Koletsis E, et al. Cardiac tumors: A retrospective multicenter institutional study. J BUON 2015;20:1115-23.  Back to cited text no. 2
Jha NK, Khouri M, Murphy DM, Salustri A, Khan JA, Saleh MA, et al. Papillary fibroelastoma of the aortic valve: A case report and literature review. J Cardiothorac Surg 2010;5:84.  Back to cited text no. 3
Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: A comprehensive analysis of 725 cases. Am Heart J 2003;146:404-10.  Back to cited text no. 4
Maludum O, Ugoeke N, Mahida H, Ajam F, Alrefaee A, Calderon D, et al. Heart Rhythm Case Reports 2018;5:134-7. doi: 10.1016/j.hrcr.2018.11.013.  Back to cited text no. 5
Baikoussis NG, Dedeilias P, Argiriou M, Argiriou O, Vourlakou C, Prapa E, et al. Cardiac papillary fibroelastoma; when, how, why? Ann Card Anaesth 2016;19:162-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
Baikoussis NG, Dedeilias P, Argiriou, M, Argiriou O, Vourlakou C, Prapa E, et al. Cardiac papillary fibroelastoma; when, how, why?. Ann Card Anaesth 2016;19:162-5.  Back to cited text no. 7
[PUBMED]  [Full text]  


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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