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Tricuspid Valve Mass: Papillary Fibroelastoma or Thrombus? A Diagnostic Dilemma
*Corresponding author: Manjusree Guha, Department of Cardiac Anaesthesia, Sir Gangaram Hospital, New Delhi, India. manjusree.guha21@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Guha M, Maheshwari A, Joshi S. Tricuspid Valve Mass: Papillary Fibroelastoma or Thrombus? A Diagnostic Dilemma. J Card Crit Care TSS. doi: 10.25259/JCCC_20_2025
Abstract
Cardiac tumors, particularly papillary fibroelastomas (PFEs), often pose diagnostic challenges due to overlapping imaging characteristics with thrombi. While transthoracic and transesophageal echocardiography have high sensitivity for detecting fibroelastomas, their specificity remains limited. Tricuspid valve involvement is rare, with most cases occurring on the aortic valve. A 30-year-old male presented with exertional breathlessness for 2 months. Echocardiography revealed a mobile echogenic mass on the tricuspid valve, suggestive of PFE. Cardiac magnetic resonance imaging confirmed a non-mitotic lobulated mass, prompting surgical excision. However, histopathological examination identified the lesion as a thrombus rather than a fibroelastoma. This case underscores the importance of histopathological confirmation in differentiating between tumor and thrombus. Despite advancements in imaging, surgical excision remains a crucial approach when embolic risk is high. This report highlights the need for a multimodal diagnostic strategy to optimize patient management and reduce misdiagnosis-related complications.
Keywords
Cardiac tumors
Echocardiography
Histopathological confirmation
Papillary fibroelastoma
Tricuspid valve mass
INTRODUCTION
Cardiac tumors are rare, with primary cardiac neoplasms accounting for <0.3% of all heart diseases. Among these, papillary fibroelastoma (PFE) is the second most common benign cardiac tumor, predominantly affecting the valvular “endocardium.”[1] While the aortic and mitral valves are the most frequently involved sites, occurrences on the tricuspid valve are rare. The clinical significance of PFE lies in its potential for embolization, which can lead to life-threatening complications such as stroke, myocardial infarction, and pulmonary embolism.
Echocardiography remains the primary diagnostic tool for cardiac tumors, providing high sensitivity for detecting valvular masses. However, its specificity is limited, as fibroelastomas and thrombi often exhibit similar morphological characteristics. Advanced imaging techniques, including transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (MRI), enhance diagnostic accuracy by assessing tissue composition and mobility.[2] Despite these advancements, histopathological analysis remains the gold standard for definitive diagnosis. Given the challenges in differentiating between fibroelastomas and thrombi through imaging alone, clinical decision-making often necessitates a multimodal approach. Early identification and appropriate management of cardiac masses are crucial to preventing severe complications, with surgical excision being the preferred strategy in cases with high embolic potential.
CASE REPORT
A 30-year-old male patient presented with a history of breathlessness on exertion for 2 months. On further evaluation, transthoracic echocardiography (TTE) revealed a mobile, well-demarcated, echogenic mass measuring approximately 4.6 × 3.5 × 2.8 cm attached to the anterior leaflet of the tricuspid valve. The mass exhibited frond-like projections and a narrow stalk attachment, highly suggestive of a PFE. The echogenicity was homogeneous, and the mass demonstrated independent mobility relative to the leaflet. There was no associated color flow aliasing or shadowing.
On TEE, the mass was visualized with higher resolution, confirming its lobulated, papillary architecture, and mobility. The stalk attachment to the anterior leaflet was clearly seen, and the mass demonstrated to-and-fro movement with the cardiac cycle. The absence of associated valvular dysfunction or significant regurgitation was noted on TEE. These findings collectively supported the provisional diagnosis of PFE, although differentiation from thrombus remained challenging.
Cardiac MRI reported a lobulated mass (4.6 cm × 3.5 cm × 2.8 cm) with non-mitotic features arising from the anterior leaflet of the tricuspid valve. Considering a high embolic potential, the patient was scheduled for excision of the mass.
Intraoperative TEE confirmed the findings [Figure 1, Video 1 and 2]. During the surgery, the structure was easily excised from the anterior leaflet. However, the tricuspid leaflets appeared healthy and slightly thickened but were functioning normally, so the valve was preserved. The histopathological examination of the excised mass was suggestive of thrombus rather than fibroelastoma. The post-operative course of the patient was uneventful, and the patient was discharged on the 9th postoperative day.
- Transgastric right ventricular-focused view showing the large mobile mass (red arrow) attached to the anterior leaflet of the tricuspid valve. The white dashed circle outlines the lobulated mass, and the white dot indicates the stalk of attachment.
Video 1:
Video 1:Deep transgastric right ventricular inflow view demonstrating the mobile, echogenic mass with frond-like projections attached to the anterior leaflet of the tricuspid valve. Video available on: https://doi.org/10.25259/JCCC_20_2025Video 2:
Video 2:Modified mid-esophageal bicaval view showing the mass protruding into the right atrium with independent mobility, confirming its attachment to the tricuspid valve leaflet. Video available on: https://doi.org/10.25259/JCCC_20_2025DISCUSSION
The diagnosis of cardiac masses, particularly those located on the heart valves, presents significant challenges. While echocardiography remains the gold standard for initial diagnosis, its limitations in differentiating between different types of cardiac masses – such as PFEs, thrombi, myxomas, and vegetations – require clinicians to adopt a multimodal approach. This case exemplifies the complexities involved in diagnosing a mass on the tricuspid valve, where the findings on TTE and TEE suggested a PFE, but histopathological analysis ultimately revealed a thrombus. The case emphasizes the importance of accurate imaging, the need for comprehensive diagnostic protocols, and the critical role of histopathological confirmation in ensuring correct diagnosis and optimal patient management.
Echocardiographic features of PFE
PFEs are the second most frequent benign cardiac tumors and usually develop from the valvular endocardium, especially the aortic and mitral valves. However, on the tricuspid valve, PFEs are a rare finding. On echocardiography, PFEs are usually known to be tiny in size, sharply defined in shape, and mobile. These characteristics are characteristic of a benign tumor that can be confused with a thrombus because there are no clear-cut features that will conclusively identify a fibroelastoma.
A classic sign of PFEs, especially on TEE, is the finding of frond-like projections that are similar to the sea anemone’s tentacles and are commonly known as “sea anemone-like” because of the appearance of the tumor. The projections are a result of tumor being attached to the endocardial surface by a thin stalk, which permits it to be mobile with the cardiac cycle. The mass surface can be stippled or glinting because of the interface vibrations at the tumor-blood interface, which are best seen in TEE imaging in Table 1.[3] The mass here had these echocardiographic characteristics, including the frond-like projections and mobility, indicative that it might be a PFE. Again, as mentioned, these characteristics may be indistinguishable from a thrombus, which represents a serious problem for correct diagnosis. This case highlights that although some echocardiographic characteristics strongly indicate PFE, absolute distinction between thrombus and PFE cannot be made with certainty on the basis of echocardiography alone.
| Feature | Papillary fibroelastoma | Thrombus | Myxoma | Vegetation |
|---|---|---|---|---|
| Typical location | Valvular endocardium (aortic/mitral/tricuspid) | Atrial walls, catheters, valve leaflets | Interatrial septum (fossa ovalis) | Valve leaflets, chordae tendineae |
| Echocardiographic appearance | Small, mobile, pedunculated with frond-like projections | Sessile or mobile, layered/ lobulated | Large, heterogeneous, gelatinous | Irregular, mobile, associated with valve destruction |
| Mobility | High | Variable | High | High |
| Echogenicity | Homogeneous, echodense | Homogeneous or layered | Heterogeneous | Mixed echodensity |
| Associated findings | Often solitary, low flow on Doppler | May have spontaneous echo contrast, atrial arrhythmias | Possible obstruction, constitutional symptoms | Valvular regurgitation, signs of infection |
| MRI features | Well-defined, hyperintense on cine images, non-vascular | Low signal intensity (thrombus), avascular | Heterogeneous with possible cystic areas | May be enhanced with gadolinium if active infection |
| Histopathology | Avascular, myxoid stroma, elastic fibers | Fibrin, red cells, platelets | Myxoid matrix with stellate cells | Fibrin, inflammatory cells, and microorganisms |
| Clinical context | Incidental or embolic events | Prothrombotic states, post-op, catheters | Constitutional symptoms, embolic risk | Infective endocarditis, fever, embolic events |
| Management | Surgical excision if embolic risk | Anticoagulation, excision if large/mobile | Surgical excision | Antibiotics and surgery if required |
(Source: Adapted from Sun et al., 2001; Gowda et al., 2003; Klarich et al., 1997; Habib et al., 2015)
Differential diagnosis of right atrial masses
A tumor in the right atrium (RA) can arise from several etiologies, and precise identification is essential due to the significant risk of embolism and death associated with these masses. The differential diagnosis encompasses primary tumors (such as myxomas), metastatic tumors, vegetations resulting from infective endocarditis, thrombi, and some artifacts. Right-sided thrombus may be linked to venous thromboembolism, medical devices such as catheters and pacemaker leads, or result from blood stasis in atrial fibrillation (AF) and cardiomyopathies in Table 1.[4]
While PFEs are typically small, mobile, pedunculated masses with frond-like projections, thrombi are often sessile, laminated structures, which can be seen in patients with conditions such as AF, stasis from central venous catheters, or those with hypercoagulable states. In this patient’s case, although the mass presented with features that could suggest a PFE, histopathological analysis revealed it to be a thrombus.
This finding reinforces the difficulty in differentiating between these two entities, as both can appear similarly on imaging studies, especially when no clear vascularity is observed, as is often the case with thrombi.[5]
Furthermore, myxomas, another type of benign cardiac tumor, are typically larger, gelatinous masses that are usually attached to the interatrial septum, rather than the valve. These tumors tend to have a heterogeneous echotexture and may exhibit mobility, but they are distinct in their size and location from PFEs. Vegetations, seen in the context of infective endocarditis, present as irregular, mobile masses often associated with valvular destruction or regurgitation.
The challenge in this case was that none of these features clearly distinguished the mass as one of the above conditions, and it was only through histopathological examination that the diagnosis of thrombus was confirmed in Table 1.[6]
This case illustrates how critical it is not to rely solely on echocardiographic features when diagnosing right atrial masses. The diagnostic tools available – TTE, TEE, and MRI – although extremely useful, have limitations when differentiating between thrombi and tumors. Therefore, clinicians should consider a comprehensive diagnostic approach that integrates imaging, clinical findings, and, most importantly, histopathological examination.
Thrombus formation and its etiology
Formation of right atrial thrombus can be affected by multiple factors, such as stasis of blood secondary to atrial arrhythmias (e.g., AF), presence of central venous catheters, hypercoagulable states (e.g., malignancy, antiphospholipid syndrome), and post-operative situations causing immobilization for extended periods. The post-operative period is characteristically associated with a hypercoagulable state secondary to surgical stress, immobilization, and possible uncontrolled thrombophilia. Here, despite no central venous catheter being inserted, the pre-operative immobility status must have been responsible for thrombus formation.
Research has demonstrated that thrombi, particularly in the RA, may occur in patients with venous stasis or in those who have ailments such as AF, which predisposes them to thromboembolism. The fact that the patient had a thrombus on the tricuspid valve may be due to the post-operative hypercoagulability and possible immobility, both of which make patients susceptible to the development of thrombus. In addition, in the present case, even though imaging presented a PFE, the diagnosis was confirmed by histopathological examination, identifying the mass as a thrombus.[7] This case highlights the importance of cautious consideration of clinical context when making a diagnosis of cardiac masses. In patients with risk factors for thrombus development, even without central catheters or AF, thrombus should be included in the differential diagnosis.
Limitations of imaging modalities
While transthoracic and TEE, along with cardiac MRI, are powerful tools in the diagnosis of cardiac masses, there are limitations in their ability to definitively differentiate between various types of cardiac masses, especially when clinical and echocardiographic features overlap, as demonstrated in this case. A critical limitation is the inability of two-dimensional imaging to offer a complete volumetric view of a mass. Three-dimensional (3D) echocardiography can offer a more detailed and accurate assessment of cardiac masses, as it allows for volumetric evaluation, providing enhanced visualizations of characteristics such as vascularity, attachment, homogeneity, and calcification.
3D echocardiography: The latest methodology
Three-dimensional echocardiography, a more recent advancement in imaging technology, is an invaluable tool for the evaluation of intracardiac masses. This technique facilitates volumetric evaluation, which is superior to the linear measurements acquired with two-dimensional echocardiography.[1] By employing cropping techniques, 3D echocardiography enables clinicians to obtain more detailed views of the mass, which includes its precise location, attachment points, and internal characteristics such as vascularity and calcification.[3] Although advanced imaging techniques such as TEE and cardiac MRI can provide detailed morphological data, differentiating between tumors and thrombi remains challenging and may require histopathological confirmation.
Unfortunately, 3D echocardiography was not performed in this case due to unavailability. The absence of this imaging modality highlights one of the limitations of current diagnostic approaches. While 3D echocardiography may provide more precise information, its availability in clinical practice remains limited, especially in resource-constrained settings. This limitation calls for a broader push for improved access to advanced echocardiography techniques in clinical environments.
Contrast echocardiography
Contrast echocardiography, which uses contrast agents to improve the visualization of cardiac structures, has shown promise in the characterization of cardiac masses. It can enhance tissue differentiation and vascularity, potentially aiding in distinguishing thrombus from tumors. However, it is not without limitations. The technique can lead to misinterpretations if the mass does not show expected vascularity or if there are issues with the contrast medium.[5]
This is particularly relevant in the current case, where contrast echocardiography was not employed. The decision to avoid contrast was based on the possibility of misinterpretation, which further underscores the need for careful selection of imaging modalities in such complex cases.
Histopathological examination: The gold standard
In the end, histopathological examination remains the definitive method for diagnosing cardiac masses. Although advanced imaging techniques can provide valuable insights into the morphology, size, and mobility of a mass, they cannot always definitively distinguish between tumors and thrombi, as evidenced by this case. In cases like this one, where imaging findings are inconclusive or ambiguous, histopathology provides the final answer and can prevent misdiagnosis, which could lead to inappropriate treatment in Table 1.[8-11] For instance, in this case, the excised mass was found to be a thrombus, despite initial imaging suggesting a fibroelastoma.
CONCLUSION
This case underscores the diagnostic complexity of differentiating between cardiac PFE and thrombus based on imaging findings alone. While transthoracic and TEE, supported by cardiac MRI, suggested a PFE due to the mass’s frond-like appearance, homogeneous echogenicity, and mobility, histopathological analysis ultimately revealed a thrombus. This highlights the inherent limitations of imaging modalities, especially in cases lacking confirmatory features such as vascularity on contrast echocardiography or detailed anatomical assessment through 3D echocardiography. The patient’s post-operative hypercoagulable state likely contributed to thrombus formation on the tricuspid valve, mimicking a tumor. Surgical excision proved both diagnostic and therapeutic, preventing potential embolic events. This report reinforces the critical role of a multimodal diagnostic approach – combining imaging, clinical assessment, and histopathology – to optimize patient management and reduce the risk of misdiagnosis.
Ethical approval:
Institutional review board approval is not required.
Declaration of patient consent:
Patient’s consent not required as patients identity is not disclosed or compromised.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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