Introduction/Hypothesis:
Abstract:Among primary benign cardiac tumors papillary fibroelastoma is the most common. Usually, papillary fibroelastomas are asymptomatic and discovered incidentally, either by echocardiography, cardiac surgery or autopsy, but sometimes they could lead to impressive clinical manifestations, such as strokes. This case involves a 63-year-old male patient with new onset atrial fibrillation and significant comorbidities, in whom papillary fibroelastoma was found on the aortic valve during pre-conversion echocardiographic evaluation. Despite initial difficulties with an attempted transesophageal echocardiography-guided removal due to coronary complications from air emboli, a successful percutaneous catheter- based procedure was later performed using a novel approach at a second institution. Multimodal imaging and careful evaluation of the expert team revealed silent cerebral infarctions, underscoring the need for comprehensive assessment and the importance of surgical intervention to prevent further embolic events. Our case highlights the critical role of multidisciplinary team and integrated cardiac and neurological imaging in managing such tumors.

Methods
Introduction:Primary cardiac tumors are rare and typically benign. Papillary fibroelastoma (PFE) is the most common type, generally presenting benign pathological findings (1). Most papillary fibroelastomas are asymptomatic and are found incidentally through echocardiography, cardiac surgery, or autopsy. However, they can sometimes lead to significant clinical issues, such as stroke caused by embolization (2,3). Therefore, a multidisciplinary heart team- comprising a cardiologist, sonographer, cardiovascular surgeon, interventional cardiologist, radiologist, and neurologist- should collaborate to ensure accurate diagnosis and assess embolization risk. This collaboration is crucial for selecting the appropriate treatment and achieving optimal clinical outcomes for each patient.

Results
Case presentation: We present the case of a 63-year-old male, admitted with new onset atrial fibrillation diagnosed during a routine cardiovascular examination. He had medical comorbidities including, but not limited to, coronary artery disease with prior three vessel artery by-pass grafting and rheumatoid polyarthritis. In the context of atrial fibrillation anticoagulation therapy was introduced, and the patient underwent a transesophageal echocardiogram (TEE) for scheduled cardioversion. Left atrial appendage thrombosis was excluded and surprisingly a small mass (6x7mm) attached to the left coronary cusp of aortic valve suggestive for PFE was discovered without valvular function impact. In completion of investigator protocol for an accurate description of the morphological characteristics of the mass on the aortic valve and to establish its relationship with surrounding structures, with the concomitant advantage of assessing the coronary arteries status, a cardiac CT angiography with contrast agent was performed. Its result confirmed the findings of previously performed TEE and concluded by-pass grafts with minor atherosclerotic lesions.  During the differential diagnosis work-up for the cardiac mass, endocarditis, myxoma, thrombophilia, antiphospholipid syndrome, and lupus were all ruled out. Brain MRI performed for assessment of eventual cerebral embolization showed chronic lacunar infarction in the left corona radiata. This finding was considered as being a silent embolization. After further review of the case the recommendation was to perform a 2D and 3D TEE guided AlphaVac PFE removal. Procedure was abandoned due to ST elevation and severe bradycardia rising the concern of myocardial ischemia. Invasive coronary angiography revealed that the intraprocedural ST changes was in the context of air emboli which further aspirated with manual thrombectomy aspiration catheter from the venous graft on the left circumflex artery, with complete resolution of the microbubbles and consequently ST segment elevation was resolved. Given patient’s comorbidities and high cardiovascular surgical risk for a second sternotomy and in shared decision making with the patient, a second percutaneous approach for mass excision was attempted at another institution with a novel technique. Cerebral embolic protection was insured by using a Sentinel device and permanent Heparin infusion during the entire procedure, So, he underwent a successful percutaneous electrosurgical laceration of the stalk with successful aortic continuous flow mechanical aspiration of mass. Post-procedural echocardiography excluded aortic regurgitation or pericardial effusion. The specimen sent to pathology department confirmed to be a PFE. The patient was discharged next day after the intervention, with good clinical appearance at the follow-up visits.

Conclusion
Discussion: Primary cardiac tumors have a low prevalence of 0.02%. PFE is the most prevalent benign cardiac tumor with predominant valvular location. The most common location is on the aortic valve surface (4). Despite their benign nature, they can be associated with serious embolic events, primarily affecting the brain (5). In such cases, surgical resection of PFE is mandatory to prevent further embolic events (6). This case highlights the importance of integrating multimodality cardiac imaging in diagnosis workup but also for intraprocedural guidance. Additionally, for patients with cardiac masses, neuroradiology may reveal previously undetected asymptomatic strokes (7). This evaluation should be considered for all cases even if the patient has no prior history of brain infarction, for embolic risk stratification.
References:
Klarich KW, Enriquez- Sarano M, Gura      GM, Edwards WD, Tajik AJ, Seward JB. Papillary fibroelastoma:      echocardiographic characteristics for diagnosis and pathological      correlation. J Am Coll Cardiol. 1999, 30:784-790.
Covington MK, Young PM, Bois MC,      Maleszeweski VA, Dearani JA, Klarich KW. Clinical impact of cardiac      fibromas. Am J Cardiol. 2022, 1:182:95-103. Doi:      10.1016/j.amjcard.2022.06.062.
Kurmann RD, El-Am EA, Sorour AA,      Ahmad A, Lee AT, Klarich KW et al. Papillary Fibroelastoma Growth: A      Retrospective Follow-Up Study of Patients with Pathology-Proven      Papillary Fibroelastoma. J Am Coll Cardiol. 2021 Apr 27;77(16):2154-2155.      doi: 10.1016/j.jacc.2021.02.027. PMID: 33888255
Maleszewski JJ, Anavekar NS, Moynihan      TJ, Klarich KW. Pathology, imaging, and treatment of cardiac tumours. Nat      Rev Cardiol. 2017, 14(9):536-549. Doi: 10.1038/nrcardio.2017.47.
. Kurmann R, El-Am E, Ahmad A, Abbasi      MA, Mazur P, Klarich K et al. Cardiac Masses Discovered by Echocardiogram;      What to Do Next? Struct Heart. 2023, 10;7(4):100154. doi:      10.1016/j.shj.2022.100154.
Mazur P, Kurmann R, Klarich KW,      Dearani JA, Arghami A, Daly RC et al. Operative management of cardiac      papillary fibroelastomas. J Thorac Cardiovasc Surg. 2024,      167(3):1088-1097. doi:10.1016/j.jtcvs.2022.06.022.
Howard AR, Aldea GS, Shapira OM,      Kasznica JM, Davidoff R. Papillary fibroelastoma: increasing recognition      of a surgical disease. The Annals of Thoracic Surgery. 1999, 68(5),      1881-5, doi.org/10.1016/S0003-4975(99)00860-7;

**Introduction/Hypothesis:**
**Abstract:**Among primary benign cardiac tumors papillary fibroelastoma is the most common. Usually, papillary fibroelastomas are asymptomatic and discovered incidentally, either by echocardiography, cardiac surgery or autopsy, but sometimes they could lead to impressive clinical manifestations, such as strokes. This case involves a 63-year-old male patient with new onset atrial fibrillation and significant comorbidities, in whom papillary fibroelastoma was found on the aortic valve during pre-conversion echocardiographic evaluation. Despite initial difficulties with an attempted transesophageal echocardiography-guided removal due to coronary complications from air emboli, a successful percutaneous catheter- based procedure was later performed using a novel approach at a second institution. Multimodal imaging and careful evaluation of the expert team revealed silent cerebral infarctions, underscoring the need for comprehensive assessment and the importance of surgical intervention to prevent further embolic events. Our case highlights the critical role of multidisciplinary team and integrated cardiac and neurological imaging in managing such tumors.

**Methods**
**Introduction**:Primary cardiac tumors are rare and typically benign. Papillary fibroelastoma (PFE) is the most common type, generally presenting benign pathological findings (1). Most papillary fibroelastomas are asymptomatic and are found incidentally through echocardiography, cardiac surgery, or autopsy. However, they can sometimes lead to significant clinical issues, such as stroke caused by embolization (2,3). Therefore, a multidisciplinary heart team- comprising a cardiologist, sonographer, cardiovascular surgeon, interventional cardiologist, radiologist, and neurologist- should collaborate to ensure accurate diagnosis and assess embolization risk. This collaboration is crucial for selecting the appropriate treatment and achieving optimal clinical outcomes for each patient.

**Results**
**Case presentation**: We present the case of a 63-year-old male, admitted with new onset atrial fibrillation diagnosed during a routine cardiovascular examination. He had medical comorbidities including, but not limited to, coronary artery disease with prior three vessel artery by-pass grafting and rheumatoid polyarthritis. In the context of atrial fibrillation anticoagulation therapy was introduced, and the patient underwent a transesophageal echocardiogram (TEE) for scheduled cardioversion. Left atrial appendage thrombosis was excluded and surprisingly a small mass (6x7mm) attached to the left coronary cusp of aortic valve suggestive for PFE was discovered without valvular function impact. In completion of investigator protocol for an accurate description of the morphological characteristics of the mass on the aortic valve and to establish its relationship with surrounding structures, with the concomitant advantage of assessing the coronary arteries status, a cardiac CT angiography with contrast agent was performed. Its result confirmed the findings of previously performed TEE and concluded by-pass grafts with minor atherosclerotic lesions.  During the differential diagnosis work-up for the cardiac mass, endocarditis, myxoma, thrombophilia, antiphospholipid syndrome, and lupus were all ruled out. Brain MRI performed for assessment of eventual cerebral embolization showed chronic lacunar infarction in the left corona radiata. This finding was considered as being a silent embolization. After further review of the case the recommendation was to perform a 2D and 3D TEE guided AlphaVac PFE removal. Procedure was abandoned due to ST elevation and severe bradycardia rising the concern of myocardial ischemia. Invasive coronary angiography revealed that the intraprocedural ST changes was in the context of air emboli which further aspirated with manual thrombectomy aspiration catheter from the venous graft on the left circumflex artery, with complete resolution of the microbubbles and consequently ST segment elevation was resolved. Given patient’s comorbidities and high cardiovascular surgical risk for a second sternotomy and in shared decision making with the patient, a second percutaneous approach for mass excision was attempted at another institution with a novel technique. Cerebral embolic protection was insured by using a Sentinel device and permanent Heparin infusion during the entire procedure, So, he underwent a successful percutaneous electrosurgical laceration of the stalk with successful aortic continuous flow mechanical aspiration of mass. Post-procedural echocardiography excluded aortic regurgitation or pericardial effusion. The specimen sent to pathology department confirmed to be a PFE. The patient was discharged next day after the intervention, with good clinical appearance at the follow-up visits.

**Conclusion**
**Discussion**: Primary cardiac tumors have a low prevalence of 0.02%. PFE is the most prevalent benign cardiac tumor with predominant valvular location. The most common location is on the aortic valve surface (4). Despite their benign nature, they can be associated with serious embolic events, primarily affecting the brain (5). In such cases, surgical resection of PFE is mandatory to prevent further embolic events (6). This case highlights the importance of integrating multimodality cardiac imaging in diagnosis workup but also for intraprocedural guidance. Additionally, for patients with cardiac masses, neuroradiology may reveal previously undetected asymptomatic strokes (7). This evaluation should be considered for all cases even if the patient has no prior history of brain infarction, for embolic risk stratification.
**References**:
1. Klarich KW, Enriquez- Sarano M, Gura      GM, Edwards WD, Tajik AJ, Seward JB. Papillary fibroelastoma:      echocardiographic characteristics for diagnosis and pathological      correlation. J Am Coll Cardiol. 1999, 30:784-790.
2. Covington MK, Young PM, Bois MC,      Maleszeweski VA, Dearani JA, Klarich KW. Clinical impact of cardiac      fibromas. Am J Cardiol. 2022, 1:182:95-103. Doi:      10.1016/j.amjcard.2022.06.062.
3. Kurmann RD, El-Am EA, Sorour AA,      Ahmad A, Lee AT, Klarich KW et al. Papillary Fibroelastoma Growth: A      Retrospective Follow-Up Study of Patients with Pathology-Proven      Papillary Fibroelastoma. J Am Coll Cardiol. 2021 Apr 27;77(16):2154-2155.      doi: 10.1016/j.jacc.2021.02.027. PMID: 33888255
4. Maleszewski JJ, Anavekar NS, Moynihan      TJ, Klarich KW. Pathology, imaging, and treatment of cardiac tumours. Nat      Rev Cardiol. 2017, 14(9):536-549. Doi: 10.1038/nrcardio.2017.47.
5. . Kurmann R, El-Am E, Ahmad A, Abbasi      MA, Mazur P, Klarich K et al. Cardiac Masses Discovered by Echocardiogram;      What to Do Next? Struct Heart. 2023, 10;7(4):100154. doi:      10.1016/j.shj.2022.100154.
6. Mazur P, Kurmann R, Klarich KW,      Dearani JA, Arghami A, Daly RC et al. Operative management of cardiac      papillary fibroelastomas. J Thorac Cardiovasc Surg. 2024,      167(3):1088-1097. doi:10.1016/j.jtcvs.2022.06.022.
7. Howard AR, Aldea GS, Shapira OM,      Kasznica JM, Davidoff R. Papillary fibroelastoma: increasing recognition      of a surgical disease. The Annals of Thoracic Surgery. 1999, 68(5),      1881-5, doi.org/10.1016/S0003-4975(99)00860-7;

A papillary fibroelastoma hidden behind the curtain of new onset atrial fibrillation…

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.