Papillary Fibroelastoma Arising From the Coumadin Ridge: A Rare Extravalvular Cardiac Tumor Diagnosed by Multimodality Imaging

Papillary fibroelastoma (PFE) is the most common benign primary cardiac tumor in adults, yet its occurrence on the Coumadin ridge remains exceptionally rare. Here, we report a case of an 86-year-old woman with paroxysmal atrial fibrillation, sick sinus syndrome, and a dual-chamber pacemaker who was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. On transesophageal echocardiography (TEE), an 11 × 9 mm highly mobile, pedunculated mass with frond-like appearance was found attached to the Coumadin ridge that had the characteristic of PFE. A prior cardiac CT from 2021 confirmed that the mass had been present for at least four years, ruling out acute infective endocarditis. Given the patient’s advanced age and significant comorbidities, surgical resection was deferred in favor of conservative management with serial imaging surveillance. This case highlights the importance of multimodality cardiac imaging (particularly three-dimensional TEE and cardiac CT) in characterizing cardiac masses, distinguishing PFE from endocarditic vegetations, and guiding individualized management in high-surgical-risk patients.