the papillary fibroelastoma ( pfe ) is a rare and benign primary cardiac tumor , and the most frequently found tumor occurring in the cardiac valves .
pfe has been found most often on valve leaflets , chordae tendineae , and both ventricles .
we describe an interesting case of pfe originating from the anterior leaflet of the mitral valve mimicking vegetation .
a 52-year - old woman was readmitted to a regional hospital due to wound infection after a previous mastectomy due to breast cancer .
she received antibiotics for 2 weeks to treat a suspicious vegetation apparent on transthoracic echocardiography ( fig . 
because the size of the cardiac mass had not changed , the patient was referred to our hospital for further evaluation . 

figure  1:transthoracic echocardiography shows a mobile and spherical mass of 1.0 cm in size attached to anterior mitral leaflet .
parasternal long - axis view ( a ) and an apical four - chamber view ( b ) .
transthoracic echocardiography shows a mobile and spherical mass of 1.0 cm in size attached to anterior mitral leaflet .
parasternal long - axis view ( a ) and an apical four - chamber view ( b ) .
gross specimen of excised mass reveals a friable mass with frond - like surface . on physical examination ,
the laboratory findings revealed 15 700/mm leucytosis , platelet count 3 251 000/mm and erythrocyte sedimentation rate 53 mm / h .
tee revealed a mass of > 1.0 cm in size , mobile , attached to anterior mitral leaflet on the atrial aspect , and round with a homogenously speckled surface ( fig . 
the cardiac mass was removed by surgery in order to reduce the risk of embolism as well as to rule out the infective endocarditis . under standard cardiopulmonary bypass ,
the mass was removed using a shave excision technique . however , there was significant mitral regurgitation after mass excision , and following excision of the mitral leaflets and chordae , a mechanical valve was implanted with preservation of the subvalvular apparatus of the mitral valve .
macroscopically , the excised lesion was composed of a soft beige tissue with micropapillary projections and lobulated surface of 1.2  0.5 cm , entirely processed ( fig . 
after the surgical excision , the mass was fixed in formalin , paraffin embedded , sectioned at 3 m thick and stained conventionally with hematoxylin and eosin .
the histology examination revealed a papillary lesion composed of numerous papillary fronds with an acellular fibro - hialinous stroma ( fig . 
2c ) . in the excised margin in close contact with the non - pathologic endocardial tissue
, the lesion has an infiltrative - like appearance , but the excisional margin itself was free of neoplasia .
a higher magnification demonstrates a myxoid papillary structure lined by endothelial cells that express endothelial cell markers ( fig . 
the postoperative course was uneventful , and the patient was discharged in a satisfactory condition on the seventh day . 

low magnification demonstrates a papillary configuration of paucicellular fronds ( a , b h - e 10 ) .
a higher magnification demonstrates a myxoid papillary structure lined by endothelial cells that express endothelial cell markers ( c h - e 40 , d cd 34 20 ) .
low magnification demonstrates a papillary configuration of paucicellular fronds ( a , b h - e 10 ) . a higher magnification demonstrates a myxoid papillary structure lined by endothelial cells that express endothelial cell markers ( c h - e 40 , d cd 34 20 )
different mechanisms such as prior damage to the endothelium , hamartomatous origin and organizing emboli to cause pfe .
if trauma is mechanically induced , pfe can occur in proximity to the iatrogenic injury .
the presence of fibrin and elastin fibers within the fronds supports the hypothesis that pfe may arise from organizing thrombi .
one of the most discussed theories is the microthrombus theory which stresses the fact that these lesions are acquired and they originate as small thrombi that serve as a nidus for further ecrescents to minor endothelial site injury of the valves or to previous diseased valves .
pfe is considered also a hamartomatous growth of endocardial tissue that may give rise to neurologic symptoms when located on the left side of the heart .
pfe is similar to lambl 's excrescences , but the site may be anywhere on the endocardium , and the lesion is large enough to potentially cause symptoms by embolization of attached thrombi or prolapse into a coronary orifice [ 4 , 5 ] .
the other theory is that pfes are true tumoral lesions that predominantly affect heart valves .
the differential diagnosis of pfe includes other cardiac tumors , thrombus , vegetation and lambl 's excrescences .
in contrast to myxoma , there are no vascular structures and associated inflammation within the fronds .
pfe has several characteristic findings that may help to differentiate it from thrombus   or vegetation .
similar to vegetations , pfe is usually found on cardiac valves ; however ; pfe is often a solitary mass , usually of small size ( < 1 cm ) , usually at the mid - portion of valve leaflets and with a frond - like characteristic surface .
however , pfe may lack some of these findings , whereas vegetations may represent many of these characteristics .
for that reason , pfe can often be differentiated by clinical information , blood cultures and laboratory tests . in this case
, there was evidence of wound infection , so the clinical information was quite misleading .
although pfes are benign , they can cause serious complications such as thromboembolism , myocardial ischemia , stroke and sudden death .
surgical excision of pfe is recommended for symptomatic patients and asymptomatic patients with a fragile mass nature and frond - like papillary tissues of the tumor itself [ 8 , 9 ] .
right - sided pfes are asymptomatic and rarely cause pulmonary embolism , whereas left - sided can cause life - threatening complications .
acute myocardial infarction , caused by a tumor occluding the coronary ostium or by embolization , may be the presenting symptom .
cerebral embolization , either of fibrin or of a tumor fragment , has also been reported ; this may present as a transient ischemic attack or visual disturbance .
considering the patient 's age , tumor mobility and tumor size , we decided to remove the cardiac mass to prevent potential complications such as embolization .
the treatment of choice for pfe is surgical excision , which is safe without causing significant morbidity or mortality . when valvular involvement is present , excision with valve repair or replacement is curative .
this report has received the ethics committee approval . we confirm that we have obtained consent to publish such an information from the patient to report individual patient data .
 the papillary fibroelastoma ( pfe ) is a rare and benign primary cardiac tumor , and the most frequently found tumor occurring in the cardiac valves . with the introduction of echocardiography , the diagnosis of these tumors in living patients has been reported sporadically . 
 the pfes have been found most often on valve leaflets , chordae tendineae , and both ventricles . 
 we describe an interesting case of the pfe originating from the anterior leaflet of the mitral valve mimicking vegetation . 
 the patient underwent successful surgical removal of the pfe . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT