To review the diagnostic evaluation and treatment approach for a rare case of ischemic stroke in anterior cerebral artery (ACA) territory in a patient found to have a tricuspid valve papillary fibroelastoma and large patent foramen ovale (PFO), the first reported case managed by a percutaneous debulking procedure.

While intracardiac masses in stroke patients most often represent infective valvular vegetations or ventricular thrombi, primary cardiac tumors including rare entities such as papillary fibroelastomas (PFE) are another known risk factor for formation of thromboemboli worthy of diagnostic consideration.

Case report

A 60 year-old female with diabetes, hypertension, and recently treated urinary tract infection presented to the hospital with acute onset left sided weakness and was diagnosed with a right ACA stroke. Initial transthoracic echo (TTE) showed a 15 x 11 mm mobile mass attached to the posterior leaflet of the tricuspid valve, with transesophageal echo (TEE) confirming the finding and identifying a large PFO and atrial septal aneurysm. Extensive clinical evaluation for infection over 10 days revealed no evidence of infective endocarditis, at which time differential diagnosis continued to include culture-negative/marantic endocarditis, thrombus, or tumor. After multi-disciplinary discussion, a percutaneous debulking procedure was chosen due to the patient’s high surgical risk following the recent stroke. Under the guidance of intracardiac echocardiography (ICE), the PFE was debulked and largely removed while the patient was supported on ECMO (VV). The procedure was well-tolerated and she was discharged to home on aspirin.

We report the first case describing percutaneous resection of a histopathologically confirmed tricuspid PFE, additionally raising the possibility that it caused a stroke by paradoxical embolism. While management of PFE remains controversial, this case demonstrates that percutaneous debulking procedures can be a viable alternative to open surgery in high-risk surgical candidates.