Case 190: papillary fibroelastoma of the pulmonary valve.

Transesophageal echocardiography revealed a 1-cm mobile round mass attached to the posterior leaflet of the pulmonary valve (Fig 1). During systole, the entire mass prolapsed into the main pulmonary trunk. There was also an accompanying mild (grade 1 of 4) pulmonary regurgitation. Most of the lesion was hyperechoic, but a few echolucencies were suspected within the mass. In addition, a three-dimensional transesophageal echocardiographic examination was performed (Fig 2; Movie 1 [online]). These images show even bet ter the prolapse during systole in the right ventricular outflow tract and the slightly irregular contour of the small mass. For further evaluation of the tissue characteristics of the mass, cardiac MR imaging was performed. Figures 3 and 4 show a 1.0 3 0.7 cm soft-tissue mass attached to the ventricular side of History A 64-year-old male nonsmoker with a history of hypertension and morbus Ménière (Ménière disease) who had undergone a previous appendectomy presented with fatigue and bradycardia. Laboratory tests did not reveal any relevant abnormalities. At physical examination, normal breath sounds and no heart murmurs were heard. Chest radiography demonstrated a normal cardiac silhouette and clear lung fields. Electrocardiography showed sinus rhythm with a normal axis. The indication for transthoracic echocardiography was evaluation of bradycardia of unknown origin. Because of the suggestion of a structure closely related to the pulmonary valve, transesophageal echocardiography was performed. For further tissue characterization, cardiac magnetic resonance (MR) imaging also was performed, and the resultant images are shown.