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Aortic papillary fibroelastoma as an unusual cause of angina: insights from multimodality imaging.

A 61-year-old woman with no risk factors for cardiovascular disease presented to her local hospital with symptoms of exertional angina. The resting ECG was unremarkable, but during exercise treadmill testing, the patient had her usual symptoms associated with >2-mm downsloping ST-segment depression in the inferolateral leads, which took 13 minutes to resolve. Urgent coronary angiography revealed a normal left main stem, left anterior descending artery, and circumflex artery (Figure 1; online-only Data Supplement Movie I), but right coronary artery cannulation proved impossible. The patient had chest pain during the procedure, and an aortogram was performed both to exclude dissection and to attempt to identify the right coronary artery (Figure 1; online-only Data Supplement Movie II). There was no dissection, but the right coronary artery was still not seen. As a result, contrast-enhanced 64-slice computed tomography coronary angiography was requested. This showed a small, anomalous right coronary artery but also revealed a well-defined low-attenuation filling defect consistent with a mass adjacent to the left coronary cusp of the aortic valve (Figure 1). To obtain better tissue characterization of this mass, cardiovascular magnetic resonance was performed. This demonstrated a mobile, noncalcified spherical structure attached to the aortic valve with intermediate signal intensity …