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Review

Multifocal ‘‘tapete’’ papillary fibroelastoma
K B Law,1 K R B Phillips,1 R J Cusimano,2,3 J Butany1,2
1

Department of Pathology,
Toronto General Hospital/
University Health Network,
Toronto, Ontario, Canada;
2
Faculty of Medicine, University
of Toronto, Toronto, Ontario,
Canada; 3 Division of Cardiac
Surgery, Peter Munk Cardiac
Centre, Toronto General
Hospital, Toronto, Ontario,
Canada
Correspondence to:
Professor J Butany, Department
of Pathology, Toronto General
Hospital, 11th floor, 200
Elizabeth Street, Toronto, ON
M5G 2C4, Canada; jagdish.
butany@uhn.on.ca
Accepted 22 July 2009

ABSTRACT
Papillary fibroelastomas (PFEs) are benign cardiac tumours
that typically arise on diseased aortic or mitral valves.
Usually solitary, PFEs are characterised by numerous
frond-like branches attached to the valve surface by a
single stalk, elastic tissue present within the central core,
and the appearance of a sea anemone when immersed in
water. PFEs have a predilection for men with a mean age
of 56 years. A very rare case of a 25-year-old man with
multiple lesions on the aortic and mitral valves and a large
confluent ‘‘carpet-like’’ lesion in the left ventricular cavity
is presented. Admitted with a significant left middle
cerebral artery stroke and hemiplegia, investigations
showed a left ventricular outflow tract lesion, with
surgical excision displaying a multifocal ‘‘carpet-like’’ PFE.
Histopathological examination showed various lesions
presenting with a short stem, several fronds arising from
each stem like a ‘‘tree trunk’’, and elastic tissue within the
central core. This case is presented, along with a review
of 833 reported cases of PFEs published after the year
2001. It is believed that this is the first reported instance
of surgically resected and morphologically confirmed
multiple PFEs seen and removed at one operation.

Primary cardiac tumours are rare, with an incidence of 0.001–0.030%,1 with papillary fibroelastomas (PFEs) being the most common primary
cardiac tumour.2 Seventy-five per cent of primary
cardiac tumours are benign, and PFEs are the
second most common type of benign tumour of
the heart, following myxomas.1 PFEs typically arise
from diseased aortic or mitral valve endocardium
on the flow surface.1 3 The tumour occurs predominantly on the left side of the heart,2 4 and the
majority are solitary lesions. PFEs are often
believed to be associated with trauma and the
wear-and-tear of valves.5 In our case, there were
multiple lesions on the aortic and mitral valves and
a confluent ‘‘carpet-like’’ lesion on the left ventricular myocardium. Due to its ‘‘carpet-like’’
appearance, the name ‘‘tapete’’, which is Latin for
carpet, has been chosen to delineate the PFE.

was commenced despite negative thrombophilia
work-up. He had minor thalassaemia, but no sickle
cell disease or trait. He tested negative for AP/
anticardiolipin antibodies. A repeat TEE was
performed one month later and showed no change
in the size of the lesion. At this point, the diagnosis
of a primary cardiac tumour, possibly a myxoma,
was suggested and surgical excision was planned.

Surgical procedure
Given the LVOT location seen at preoperative TEE,
the initial surgical approach was through the aortic
root. Multiple lesions were found in the left
ventricle, mainly evident on the LVOT septum.
These lesions appeared to ‘‘carpet’’ the inside of the
left ventricle with varied thickness, including the
chordae tendinae, papillary muscle heads and the
free left ventricular endocardium (fig 1). The aortic
valve leaflets as well as the atrial surface of the
mitral valve leaflet (fig 2) were also involved.
Endocardial fibrosis was present on the endocardium. All visible endocardial lesions were excised.
To remove the lesions on the chordae tendinae and
papillary muscle heads, mitral valve replacement
with a St Jude bileaflet mechanical valve was
necessary. No lesions were noted in either the left
atrium or aorta. A small linear thrombus (despite
anticoagulation) appeared to cover one part of the
left ventricular septal fibroelastoma (fig 3A). He
made an uneventful recovery and was discharged
home on lifelong warfarin therapy. Five months
later he has continued to improve, having recovered some speech and ambulation. There have been
no further clinical events and he is free of cardiac
limitation.

PATHOLOGY
The surgically excised specimens were photographed and examined grossly. The valvular lesions

CASE REPORT
A 25-year-old man was admitted after suffering a
major stroke consistent with left middle cerebral
artery (MCA) occlusion by embolism, leaving him
hemiplegic and aphasic. Investigations revealed
evidence of three previous cerebrovascular accidents (CVAs).
A two-dimensional transoesophageal echocardiogram (2D-TEE), performed to determine the
aetiology of the stroke, showed a 9.0 mm 6
3.0 mm mass in the left ventricular outflow tract
(LVOT) not evident on the transthoracic echocardiogram (TTE). When pulmonary emboli were
discovered on a cardiac CT scan, anticoagulation
1066

Figure 1 Intraoperative photograph showing three
septal, subaortic lesions with PFE also present on the
endocardium. A, aorta; B, aortic valve; arrows, papillary
fibroelastomas on interventricular septum of the left
ventricular outflow tract.
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Figure 2 Multiple, ‘‘confluent’’, soft lesions (arrows) carpeting the
anterior mitral leaflet on the atrial aspect.
were small, but present on the rough zone of the valves as well
as on the entire flow surface of each valve (fig 2). There were
four myectomies; each showed patchy, shiny, white lesions
(fig 3A). Details of the lesions were best demonstrated by
immersing the specimens in water (fig 3B), where the fronds or
sea anemone-like branches were clearly seen.

HISTOLOGY
Histologically, the lesion was comprised of several narrow bases
with frond-like branches attached to them (fig 4). These frondlike lesions were predominantly comprised of a mucopolysaccharide-rich matrix (fig 5) with some collagen and varying
amounts of elastic tissue (fig 6). The appearance is that of a
papillary fibroelastoma, which instead of being a single lesion is
‘‘carpet-like’’ and at multiple sites. We therefore have a
multifocal PFE.

DISCUSSION
PFEs are benign tumours that have an incidence of 0.001–
0.030%.1 Surgically excised valves are often not sectioned,
therefore the actual incidence of PFEs, especially small lesions,
may not be accurately recognised. Most cases that are identified
are larger lesions discovered incidentally or by echocardiography.3 There has been controversy concerning classification of

Figure 4 (A–C) The endocardium (+) shows two lesions; one large (*)
and the other smaller. Both are similar in structure with a short stem
(arrows) and several fronds arising from each stem (or ‘‘tree trunk’’)
(stain: (A) H&E, original magnification 62.5; (B) Movat pentachome,
original magnification 62.5). (C) The small lesion is shown with a largely
myxoid core, with minimal collagen, and elastic tissue (black areas)
present (arrows) (stain: Movat pentachrome, original magnification
610.0).
PFEs as tumours. Some studies have suggested the possibility
that they are congenital malformations, or the result of an
inflammatory reaction. However today, PFEs are accepted to be
true neoplasms.8 PFEs are found predominantly in men, with a
mean age at detection from the review of literature of 56 years
(table 1), compared to the published mean age at detection of 60
years.7 Our case involved a 25-year-old man, an age of incidence
which is extremely rare for this type of lesion. In our case,
fragments of the tumour, or possibly a thrombus which formed
on it, may have embolised and led to the cerebrovascular
accidents.

Figure 3 (A, B) One myectomy specimen showing the small linear
thrombus (arrow), despite anticoagulation, noticed by the surgeon within
one area of the papillary fibroelastoma on the septal cardiac muscle.
(B) Lesions on the cardiac muscle immersed in water showing the
typical appearance of the papillary fibroelastoma.
J Clin Pathol 2009;62:1066–1070. doi:10.1136/jcp.2009.070243

Review of the literature
A review of the English language literature was performed using
PubMed (US National Library of Medicine) to identify
previously published cases of PFEs between 1997 and 2008.
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Figure 5 Section of a mitral valve showing multiple frond-like
structures on the flow surface (arrows). Each has a mucopolysaccharide
stroma and the large one has the beginnings of elastic tissue in its core.
Very little collagen is noted (stain: Movat pentachrome, original
magnification 65.0).
The following search terms were used: primary cardiac
tumours, papillary fibroelastoma, multiple papillary fibroelastomas, cardiac valve tumours, Lambl’s excrescences, and
myxoma (table 1). The literature reviewed ranged between
1997 and 2008. Of the 833 cases reviewed, 58% were male and
42% female with a mean age at detection of 56 years. Tumour
size ranged from 2 to 70 mm, although at our institution we
have yet to see a PFE with a size close to 70 mm. The two most
common locations of PFEs were the aortic valve with a 44–52%
occurrence, and the mitral valve with a 35–40% occurrence.
Clinical presentations varied, but TIA, dyspnoea, chest pain and
symptoms that could be likened to syncope were reported in the
majority of cases. Ninety-eight per cent of the reviewed cases
had been studied by TEE and TTE, 1% by TEE alone, and 1% by
either TTE alone or other imaging modalities such as CT scan or
MRI. In our case, a CT scan of the chest did not show any mass

Figure 6 A large tumour arising from the endocardium showing a
fibrovascular core (asterisk) and an elastin rich core in each frond
(arrow) (stain: Movat pentachrome, original magnification 610.0).
lesions in the heart (including the valves and endocardium).
Excision was the most common form of management in 79% of
reviewed cases, excision and valve repair were performed in 11%
of cases, and excision and valve replacement were performed in
10% of cases.

PFE appearance
PFEs usually appear as highly mobile spherical masses with a
maximum diameter of 10 mm.3 The lesions are generally
solitary with an opalescent white appearance and numerous
frond-like branches attached to the valve surface by a single
stalk.4 They have been reported as having the appearance of a
sea anemone when immersed in water, with multiple papillary
fronds easily seen arising from the central stalk1 5 (fig 3). These
fronds are covered by endothelial cells (fig 7) and have a loose
mucopolysaccharide-rich tissue layer on a connective tissue
core.2 Elastic fibres are also present within the central core.4 6

Table 1 Previously reported cases of papillary fibroelastoma
Reference

Cases

*Gowda et al (2003)13 725

Sex

Mean age

Size (mm)

Location

Clinical presentation

Tests

Management

70

2.0–70.0
–

54

2.0–27.0

32% TIA/stroke
13% Angina
52% Dyspnoea
32% Thromboembolism
30% TIA

TEE, TTE

62

44% AV
35% MV
52% AV
18% LVOT
50% AV

81% Excision
10% Excision, VRT
83% Excision
9% Excision, repair
40% MVR

51

9.0–15.0

40% MV
AV

20% Stroke
Vertigo, hypertension, history of tight TTE, TEE
chest
Chest trauma, heart failure
TTE
symptoms, dyspnoea
Respiratory and renal failure
Chest x ray,
TTE
Abdominal pain, weakness
MRI, Echo
Fronto-parietal infarct, dysphasia
TTE
VSD
Echo
Routine check-up
Echo
Dyspnoea
Echo

Ngaage et al (2005)14

88

Boodhwani et al
(2007)15

10

56% M
45% F
71% M
29% F
70% M

Butany et al
(1997–2008)2 16 17

3

30% F
M
M

IVS

F

IAS

Saw et al (2001)18

3

M
F

45

6.0–7.0

Hino et al (2007)19

2

M
F

57

7.0–9.0

Darvishian et al
(2001)20

2

M

50

10.0–15.0

F

MV
MV
IVS
LVOT
LV: papillary
muscles
MV
MV

Ataxia, nausea, vomiting, vertigo
Dysphasia, vertigo, unsteady gait

TEE, TTE
TEE

30% AVRT
Excision, repair
Orthotopic heart
transplantation
Excision, repair

Excision, repair
Excision, repair
Excision, repair
Excision
AVRT, MVRT, tricuspid
annuloplasty
CT scan, TTE Open-heart mitral
valvuloplasty
CT scan, echo Open-heart mitral
valvuloplasty

*Gowda et al13 performed a systematic search of the literature using Medline; they extracted data from case reports and case series to provide a comprehensive overview of the
subject.
AV, aortic valve; AVRT, aortic valve replacement; CT, computed tomography; Echo, echocardiogram; IAS, interatrial septum; IVS, interventricular septum; LV, left ventricle; LVOT, left
ventricular outflow tract; MRI, medical resonance imaging; MV, mitral valve; MVR, mitral valve repair; MVRT, mitral valve replacement; TEE, transoesophageal echocardiogram; TIA,
transient ischaemic attack; TTE, transthoracic echocardiogram; VRT, valve replacement; VSD, ventricular septal defect.

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closing valves margins. Furthermore, PFEs have a central stalk, a
layer of elastic tissue and are not filiform like Lambl’s
excrescences. PFEs and myxomas are also histologically somewhat similar, although PFEs lack identifiable vessels within the
papillae and polygonal cells within the papillae and on the
surface of the tumour (table 2). PFEs also have an outer
localisation of myxoid matrix and laminated elastic fibres. It is
essential to see the elastic tissue to differentiate a PFE from a
Lambl’s excrescences or myxoma.7 This appearance is essentially
the one seen in our case, which allowed for confirmation of PFE.

Origin of PFE

Figure 7 (A) Sections of the tumour show papillary fronds (stain:
CD31, original magnification 65.0). (B) Higher magnification boxed area
from (A). All fronds are covered with a single layer of endothelial cells
(stain: CD31, original magnification 620.0).

Differential diagnosis
PFEs and Lambl’s excrescences are histologically very similar,
although PFEs are larger and more gelatinous than Lambl’s
excrescences which are usually thread-like in structure7 (table 2).
PFEs tend to be located on various parts of the cusps, whereas
Lambl’s excrescences are generally seen on the midline of the

The origin of PFE is still under debate, however they are often
associated with iatrogenic procedures including radiation
therapy or prior cardiac surgery involving native valve repair.9
At our institution, we have yet to see a case of a PFE on a
previously operated native heart valve. Risk factors associated
with the development of PFEs remain unclear, however age,
thoracic irradiation, cardiac valve disease, congenital heart
defect repair and open-heart surgery have been proposed.
There is often a prior known episode of rheumatic heart
disease.4 Our patient had none of the previously mentioned risk
factors or possible explanations for his tumour.
Recently, there have been reports of PFEs being associated
with several embolic states, including cerebrovascular events,
myocardial infarction, and pulmonary embolism.10 Fowles et al11
found that 34% of patients with a PFE detected at echocardiography presented with TIA/CVA symptoms and a further 2%
presented with symptoms of a pulmonary embolism.11 Emboli
often arise from papillary fronds of the tumour or from thrombi
that form ‘‘in’’ or around the tumour.11 12 Broken and embolised
fronds can be responsible for angina, myocardial infarction,
TIAs, stroke, or cardiac death.12 Our patient had three previous
CVAs, a MCA occlusion, and known pulmonary emboli. The
strokes and emboli have both been posited to have had an
association with the PFE lesion.

Table 2 Differential diagnosis for papillary fibroelastoma
Cardiac tumour

Gross findings

Papillary
fibroelastoma

c
c
c
c
c
c
c

Lambl’s
excrescences

c
c
c
c
c

Myxoma

c

c

c
c

Spherical
Typically solitary
Opalescent
White
Gelatinous
Numerous frond-like branches
attached by single stalk
Appearance of sea anemone
when immersed in water
Smaller than PFE
Thread-like
Seen on midline of closing valve
margins
Filiform
No central stalk
Attached to interatrial septum
by either broad base of narrow
pedicle
Vary from gelatinous with frondlike excrescences to a smooth,
firm mass
Organised thrombi on surface
May contain gritty calcified
areas

Histological findings
c

c
c

c

c
c

c
c
c
c

c

Ultrastructural findings

Papillary fronds: narrow, elongated,
branched
Matrix: mucopolysaccharides, elastic
fibres, rare spindle cells
Covered by layer of endothelial cells

c

Finger-like projection extending from
valve surface
No branching
No elastic fibres

c

Oval nucleus with open chromatin
pattern and inconspicuous nucleoli
Abundant eosinophilic cytoplasm
Indistinct cell borders
Ring surrounding blood vessel, often
infiltrated by mononuclear inflammatory
cells
No elastic fibres

c

c
c

c

c
c
c

Common location
(cardiac)

Connective tissue: mature collagen, irregular
longitudinal-oriented elastic fibres
Matrix: fibroblasts, mesenchymal cells
Surface endothelial cells: hyperplastic,
numerous organelles and pinocytotic vesicles

c

Connective tissue: abundant collagen fibrils21
Circular zone devoid of identifiable connective
tissue present at centre21

c

Mesenchymal cells with intermediate
filaments and cytoplasmic organelles
Vessels within papillae
Polygonal ‘‘myxoma’’ cells within papillae and
on surface of tumour
Diffuse localisation of myxoid matrix

c

c
c

c
c

c

AV
MV
TV

AV
MV
TV

LA (attached to
fossa ovalis)
RA

Modified from Burke et al.7
AV, aortic valve; LA, left atrium; MV, mitral valve; RA, right atrium; TV, tricuspid valve.

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Take-home messages

Competing interests: None.
Patient consent: Obtained.

Papillary fibroelastomas (PFEs) are the second most common
type of benign tumour of the heart.
c Typically arising from diseased aortic or mitral valves on the
left side of the heart, PFEs have a predilection for men around
56 years of age.
c Risk factors include age, thoracic irradiation, cardiac valve
disease, congenital heart defect repair and previous openheart surgery.
c Emboli often arise from papillary fronds of the tumour or from
thrombi and can break, resulting in angina, myocardial
infarction, transient ischaemic attacks, stroke, or cardiac
death.
c

An interesting phenomenon is what we call an ‘‘aborted’’
PFE, where a structure with the histology of a PFE’s fronds is
‘‘trapped’’ inside a fibrotic area, generally in the central part of
an aortic valve cusp. We believe that thrombus forms around
the small PFE, encasing it, ‘‘aborting’’ it, and prohibiting further
growth. These lesions appear to be ‘‘young’’, not excessively
collagenised, and with no inflammation or evidence of prior
trauma.
The aetiology of the ‘‘carpet-like’’ appearance of the PFE
lesion is not well understood. It is thought by some to be injury
related, similar to current thinking concerning lesions arising on
chordae tendinae or on papillary muscles. Endocardial fibrosis
could look grossly like a PFE, but would certainly not be
papillary or occur on the flow and non-flow surfaces of valves.
Being a neoplasm, it could have grown until it involved the
myocardium, and then become multifocal with further lesions
on the aortic and mitral valves. Perhaps like any neoplasm the
aetiology is and will remain unknown.

CONCLUSION
In summary, we present the case of a 25-year-old man with
multiple lesions on the aortic and mitral valves and a confluent
‘‘carpet-like’’ lesion in the left side of his heart clinically
suspicious of a thrombus or myxoma. Surgery revealed masses
on the aortic and mitral valves necessitating aortic and mitral
valve replacement, and a multifocal ‘‘carpet-like’’ lesion covering
many parts of the left ventricular endocardium. We believe that
this case is the first reported instance of surgically resected and
morphologically confirmed multiple PFE ever seen and removed
at one operation.

1070

Provenance and peer review: Not commissioned; not externally peer reviewed.

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Multifocal ''tapete'' papillary fibroelastoma
K B Law, K R B Phillips, R J Cusimano and J Butany
J Clin Pathol 2009 62: 1066-1070

doi: 10.1136/jcp.2009.070243
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