Papillary Fibroelastoma of the Tricuspid Valve Seen on Magnetic Resonance Imaging
A 72-year–old female patient with atypical chest pain and atherosclerotic risk profile was referred for cardiac magnetic resonance imaging at 3.0 Tesla (Phillips Achieva, Phillips Medical Systems, Best, The Netherlands), sus pected of having coronary artery disease. A resting ECG showed no signs of ischemia or chronic myocardial infarction (Figure 1A). Routinely performed echocardiography revealed a small suspicious mass at the tricuspid valve (Figure 1B). Cardiac magnetic resonance cine imaging revealed normal left ventricular function but, at rest, hypokinesia of the lateral wall of the basal slice. As an additional finding, an 8×8-mm, highly mobile, spherical pedunculate mass attached to the posterior tricuspid valve leaflet was found (Figure 2). T1-weighted images revealed the mass to be homogeneous but with higher signal intensity compared with myocardium. On the basis of a fat-suppression sequence, no fatty content of the tumor was found. Delayed enhancement images of the tricuspid valve tumor after administration of Gd-DTPA demonstrated hyperintense signal caused by the fibroelastic tissue of the mass. In addition, a 50% to 75% subendocardial scar of the lateral wall at basal level could be demonstrated. This lesion was located in correspondence to a wall motion abnormality at rest and was highly suspicious of ischemia due to underlying coronary artery disease. Invasive coronary angiography revealed triple-vessel disease with high-grade stenosis (Figure 3A). Bypass surgery and removal of the valvular tumor were performed.
The tumor was histologically diagnosed as a papillary fibroelastoma covered with CD31-positive endothelial cells (Figure 3B through 3D). Papillary fibroelastomas are benign avascular growths of the endocardium with a matrix consisting of mucopolysaccharides. Such a tumor is located in most cases on the aortic or mitral valve and only in approximately 10% of cases on the tricuspid valve.1
This rare case of a papillary fibroelastoma of the tricuspid valve demonstrates that cardiac magnetic resonance imaging allows characterization of suspicious tumor masses and can provide valuable guidance for surgical procedures. In addition, the case shows the combined finding of subendocardially located myocardial scar tissue, which is highly suggestive of underlying coronary artery disease. Magnetic resonance examinations are useful for detecting myocardial viability. In additional findings of cardiac masses, the characteristics of necrosis of the tumor can be described in the same session.
The online-only Data Supplement, which contains movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/117/11/e190/DC1.