Imaging findings
Echocardiography (initially transthoracic, usually followed by transesophageal)
- small, well-defined, usually pediculated mass
- attached to the valves or the endocardium
- high mobility, may prolapse into the cardiac chambers during the cardiac cycle
- “speckled” appearance with “stippling” near the edges, corresponding to the papillary fronds [1-3,9,11,12]
Fig. 1: Tricuspid valve papillary fibroelastoma in a 51-year-old man: echocardiography.
References: Dr. Raluca Rancea, "Niculae Stăncioiu" Heart Institute, Cluj-Napoca, Romania
Computed tomography (CT)
- small, hypodense mass, with irregular margins and a thin stalk
- cine ECG gated imaging: mobility [3,13,14]
Magnetic resonance imaging (MRI)
- small, round, homogeneous, pediculated mass
- attached to the valves or to the endocardium
- isointense on T1, hyperintense on T2
- cine SSFP images: hypointense, highly mobile, surrounded by turbulent flow signal [3,15,16]
- + gadolinium: usually enhances completely in the delayed phase [11]
Fig. 2: Tricuspid valve papillary fibroelastoma in a 60-year-old woman: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 3: Pulmonary valve papillary fibroelastoma in a 55-year-old woman: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 4: Mitral valve papillary fibroelastoma in a 30-year-old man: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 5: Mitral valve papillary fibroelastoma in a 62-year-old woman: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 6: Papillary muscle papillary fibroelastoma in a 65-year-old woman: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Differential diagnosis
Lambl’s excrescence
Echocardiography
- strand-like structure, highly mobile
- at the line of closure of cardiac valves
- usually multiple [3,17,18]
Thrombus
Echocardiography
- usually in the atrial appendage or in regions of ventricular aneurysm and akinesis
- echolucent, laminated appearance, irregular margins, microcavitations
- lacks pedicle
- may be multiple [3,11,19]
CT
- hypodense filling defect in a contrast pool within a cardiac chamber
- lacks mobility [13]
MRI
- + gadolinium: lack of enhancement (avascular nature), dark filling defect [16,19]
- signal intensity depends on its age:
- acute: intermediate on both T1 and T2
- subacute: low T1, high T2
- chronic (organized): low on both T1 and T2, may enhance peripherally (fibrous content) [15,16]
Fig. 7: Thrombus in right atrium in a 25-year-old man: echocardiography, magnetic resonance imaging.
References: (a) Dr. Raluca Rancea, "Niculae Stăncioiu" Heart Institute, Cluj-Napoca, Romania (b,c) Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 8: Thrombus in right atrium in a 25-year-old man: computed tomography.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Vegetation
Echocardiography
- echogenic or isoechogenic, oscillating, irregular mass
- on the low-pressure side of cardiac valves [20,21]
Fig. 9: Valvular vegetation: echocardiography.
References: Dr. Raluca Rancea, "Niculae Stăncioiu" Heart Institute, Cluj-Napoca, Romania
CT
- hypodense lesion, irregular shape, attached to the valves or paravalvular structures [13,22]
Fig. 10: Valvular vegetation: computed tomography.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
MRI
- low to intermediate signal
- mobility
- may enhance [21]
!!! Association with clinical manifestations of endocarditis and valvular destruction (perforation, abscess, pseudoaneurysm and paravalvular leakage) [3,11,16,20,21].
Echocardiography
- heterogeneous, rounded, sessile lesion, that lacks mobility [3]
Other cardiac tumors
Echocardiography
- mobile mass
- usually attached to the interatrial septum by a narrow stalk
- homogeneous or with hyperlucent areas of hemorrhage, necrosis or calcification [1]
CT
- heterogeneous low attenuation
- may present calcifications
- heterogeneous contrast enhancement
- cine ECG gated imaging: mobility [1,13]
MRI
- intermediate T1, high T2 signal
- may contain cysts, necrosis, fibrosis, hemorrhage, and calcification
- cine SSFP images: highly mobile
- heterogeneous contrast enhancement [1,15,16]
Fig. 11: Myxoma in a 74-year-old man: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
- Other: fibroma, lipoma, rhabdomyoma [1,3,15,16]
Mitral valve annular calcification
Echocardiography, CT, MRI
- mitral valve calcifications [3,16]
Fig. 12: Caseous calcification of the mitral valve in a 59-year-old woman: magnetic resonance imaging.
References: Dr. Simona Manole, Affidea-Phoenix, Cluj-Napoca, Romania
Fig. 13: Caseous calcification of the mitral valve in a 59-year-old woman: computed tomography.
References: Dr. Simona Manole, County Clinical Emergency Hospital, Cluj-Napoca, Romania