Coinciding anomalous coronary artery and papillary fibroelastoma

The primary cardiac tumors are extremely rare tumors that arise from the normal cardiac tissues. There are benign variants (mostly myxoma) and malignant tumors. Fibroelastoma (FE) is the most common primary tumor, of which myxoma is the most common subtype followed by papillary fibroelastomas (PFE).They account for the majority of primary heart valvular tumors that mainly involve the left (mitral and aortic) valves, and only few cases reported pulmonary valve PFE. We present a case of 61 year old female who had incidental pulmonary valve papillary FE finding on echo along with anomalous coronary arteries.  A 61 years old diabetic female with a medical history of sarcoidosis presented with chronic stable angina. She underwent an exercise stress test in which the patient exercised 7 min of a modified Bruce protocol was terminated afterwards due to leg pain but not chest pain. Her ECG demonstrated ST segment changes consistent with ischemia (ST segment depression of more than 1 mm in lead II,III, aVF along with lead V5 and V6). The coronary arteries were found to be angiographically clean during left heart catheterization but the procedure showed an anomalous large, long left main coronary artery originating from the right coronary cusp. Cardiac computed tomography (CT) angiogram confirmed the anomalous origin of the left main coronary artery from a common ostium with the right coronary artery originating from the right sinus of Valsalva (Figure 1A and 1B). The left main coronary was crossing between the aorta and right pulmonary outflow tract consistent with an intra-arterial course. A Trans-Thoracic It also showed pulmonary valve FE (Figure 2). Echocardiogram showed an incidental finding of multiple mobile structures attached to the pulmonic valve, with the largest one measuring 0.7  0.7 cm, whose appearance was consistent with PFE. A Trans-esophageal echo showed a mobile mass at-