Atypical presentation of a ventricular papillary fibroelastoma

Papillary fibroelastoma is the most common valvular cardiac tumor. The most common non-valvular site these tumors present is the left ventricle, where they usually manifest as ischemic strokes or myocardial infarction. Although these tumors also have a risk of embolization into the peripheral system, reports of such events are exceedingly rare.  A 77 year old female presented to the hospital for concerns of a non-healing ulcer of the right great toe. Significant findings on physical exam included a grade 3/6 systolic ejection murmur on the 5 intercostal space at mid-clavicular level on the left, which was non-radiating and of blowing quality. Her right lower extremity was noted to have diminished pulses on the popliteal and dorsalis pedis arteries. She was noted to have a partial amputation of the right great toe along with a non-healing surgical wound. Due to concern for osteomyelitis and possible surgical intervention, the patient underwent preoperative cardiac evaluation. A transthoracic echocardiogram revealed an ejection fraction of 75% and a defined, medium-sized, mobile mass within the left ventricle, measuring 18 mm x 14 mm (Figure 1). Further evaluation with a trans-esophageal echocardiogram confirmed the presence of a pedunculated mobile mass attached to the septal wall of the left ventricle. A diagnostic coronary angiogram revealed non-obstructive coronary disease. The patient underwent successful ventriculotomy and resection of the intra-cardiac tumor, which on gross specimen was noted as a gelatinous, blue-colored mass (Figure 2). Pathologic evaluation confirmed the diagnosis of papillary fibroelastoma. The patient underwent a lower extremity angiogram, which was significant for total occlusion of the anterior tibial, distal posterior tibial and proximal peroneal arteries. In the setting of peripheral arterial