Total arch replacement through a midsternotomy for a right-sided aortic arch aneurysm with an aberrant left subclavian artery

this area. In our case the rough zone was totally covered by the lesions. Operatively, the biggest part of the mass looked like an “active volcano,” and the small lesions had a “lava flow” shape (Figure 2). Given this unusual and unexpected diagnosis and the young age of the patient, we opted for exclusive tumor ablation without mitral valve replacement. Although the infiltration of valvular tissue by the PFE is impossible to prove inasmuch as the mitral valve was not extracted, the natural history of this tumor is unknown and preserving the native mitral valve could have been the optimal option. To the best of our knowledge this is the first case of invading PFE on the anterior leaflet of the mitral valve reported in the literature. Clinicians should be aware of this PFE presentation to decide how to manage such patients surgically.