A 64 year old woman presented with right hemianaesthesia and was found to have a pansystolic apical murmur with systolic and diastolic posture related plops. Echocardiography revealed a mobile mass on the mitral valve apparatus that was confirmed by magnetic resonance imaging. This was successfully excised and was proven on histopathological examination to be a fibroelastoma. Other cases of fibroelastoma from the literature are reviewed. (Heart 1998;79:301-304) Keywords: fibroelastoma; mitral valve; transient ischaemic attack A 64 four year old woman presented with an episode of right hemianaesthesia that resolved completely within a few minutes. A diagnosis of transient ischaemic attack (TIA) was made. Her past medical history included: a murmur detected at the age of 14 years, herpes zoster infection, and right breast carcinoma treated with lumpectomy and radiotherapy with no evidence of disease at five years of follow up.On examination she was in sinus rhythm with normal pulse and blood pressure. On auscultation, a pansystolic apical murmur with intermittent posture related systolic and diastolic plops were heard. There was no carotid bruit.Routine blood tests were normal except for potassium of 3.2 mmol/l (normal range 3.5-5) and erythrocyte sedimentation rate (ESR) of 40 mm in the first hour. She had a normal electrocardiogram (ECG), 24 hour Holter ECG, chest radiograph, and duplex scan of the carotid and vertebral arteries. Computed tomography (CT) of the brain showed minimal cerebral atrophy. A mobile mass attached to the mitral valve and the chordae tendineae was detected on cross sectional transthoracic echocardiography (TTE) (fig 1), and confirmed by magnetic resonance imaging (MRI) of the heart (fig 2). Right heart catheterisation and coronary arteriography were normal. Left ventricular angiography was not attempted because of the risk of embolism. ManagementThe patient was anticoagulated with intravenous heparin, and referred for surgery. At operation, a 1 cm papillary mass was found within a small left atrium. It was attached to both the middle of the free edge of the anterior leaflet of the mitral valve and to adjacent choradae tendineae (fig 3). The mass was excised, with a small piece of chorda. The patient made an uneventful recovery, her potassium was normal and she was discharged home on aspirin 75 mg daily.After 44 months of follow up she remains asymptomatic with a pansystolic apical murmur. A recent cross sectional TTE proved the presence of mild mitral regurgitation. Her ESR is normal at 9 mm in the first hour. HistopathologyHistopathology revealed papillary growth covered by a single layer of hypertrophied endothelium. The stroma was composed of a central dense amorphous fibrous core and an outer layer of loose connective tissue, consistent with a papillary fibroelastoma of the endocardium. Discussion DESCRIPTIONThe majority of fibroelastomas are valvar. When they involve the semilunar valves, either side of the leaflets could be aVected, whereas 1998;79:301-304 301

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SUMMARYA 56-year-old woman who wore hard contact lenses developed a keratitis due to Mycobacterium chelonei.

Summary:We report the clinical details of a 77 year old man with classical tetralogy of Fallot. The patient had clubbing and cyanosis at birth, and exertional squatting in childhood. He was asymptomatic as an adult until the seventh decade, when he developed biventricular failure and had an episode of bacterial endocarditis. He finally died of cerebral infarction and bronchopneumonia following abdominal surgery.In spite of investigations, the diagnosis was not made in life, but only discovered at post-mortem. A persistent ductus arteriosus was also found. Increased pulmonary blood flow via the ductus is believed to have facilitated this patient's unusual longevity.