Gladis Hefny, Juwairia Al-Ali

LEARNING OBJECTIVE

Importance of transthoracic echocardiogram and transoesophageal echocardiogram in ST-elevation myocardial infarction

CASE

A 35 years old gentleman previously healthy presented to emergency room with central chest pain.

Both his general and cardiac examination were unremarkable.

Electrocardiogram showed ST-elevation in the inferior leads, his blood tests were within normal limits apart from his high cardiac enzymes.

The patient was referred for coronary angiography.

The right coronary artery was cannulated first and it showed a proximal filling defect at the ostium that was thought to be a thrombus.

A trial of aspiration was made followed by balloon dilatation, the proximal filling defect disappeared and RCA did not show any residual stenosis, yet the thrombus was not seen in the distal artery nor in the catheter.

The left coronary system was normal.

Later on, a transthoracic    echocardiogram    was   done solving   the    riddle by revealing a long echo-dense   structure     attached     to    the   right     coronary     cusp of   the   aortic   valve   measuring   19 x 1.9 mm   that   is freely   mobile.

Otherwise,   his    EF was     60%      with normal diastolic function & hypokinetic basal/inferior wall.

A trans-esophageal echocardiogram was done which revealed two echo-dense masses seen at the right coronary cusp of the aortic valve. The largest was a freely mobile strand measuring 2 cm in length at the aortic side of the valve with the tip hitting the right coronary sinus wall, pointing to RCA ostium.

The other mass was a small 6×4 mm just under the valve on the ventricular side. The morphology of the mass was suggestive of papillary fibroelastoma.

The patient was then referred to the cardiothoracic surgeons for surgical removal of this mass for its high risk for coronary obstruction as well as distal embolization. He underwent surgery through a small submammary Incision of 7 cm width, aortic root was exposed, mass was excised (figure 4).

The aortic valve was preserved. Histopathology revealed elongated fragment of fibrous tissue and calcifications. The patient recovered well and was discharged home.

OVERVIEW

Fibroelastoma is the most common valvular tumor of the heart.

It arises more commonly from the endocardial layer of aortic valve, LVOT, or AML. It can present as systemic embolization sequelae (e.g CVA, renal ischemia), pulmonary embolism, ACS, and at rare cases as cardiac arrest.

Differential diagnosis: Fibroelastoma/ Thrombus / Vegetation/ Myxoma.

CONCLUSION

This case highlights the importance of echocardiography in identifying the etiology of acute coronary syndromes.