Fibroelastoma in an unusual location: a rare cause of multiple cerebrovascular events

Summary Fibroelastomas are rare, primary cardiac tumours with a predilection for valvular endothelium and a propensity to embolise. We present the case of a 72-year-old male with multiple cerebrovascular events (CVA) despite oral anticoagulation. Transoesophageal echocardiography (TOE) revealed a small highly mobile left atrial mass with frond-like projections attached by a stalk to the orifice of the LAA. The mass was surgically excised and confirmed to be a fibroelastoma on histological examination. This case report describes a rare but treatable source of multiple cerebrovascular events and highlights the utility of TOE in the assessment of cardiac embolic source. Learning points: Fibroelastomas are most commonly found on left-sided heart valves (aortic > mitral) and have the potential to cause systemic emboli associated with significant morbidity and mortality. A left atrial appendage (LAA) mass in a patient presenting with cerebrovascular events does not always represent thrombus. Uncommon aetiologies such as a cardiac tumour should be considered in the differential diagnosis. Transthoracic echocardiography (TTE) does not provide an accurate assessment of the LAA and should not be used to detect pathology within this structure. Transoesophageal echocardiography (TOE) is superior to TTE in imaging the LAA and provides a complete delineation of its anatomy. In addition, TOE can detect very small highly mobile lesions (as described in this case), which may be missed on other imaging modalities.