Incidental Finding of a Myxoma of Unusual Location in an Elderly Patient

We present a case of an elderly patient with an incidental finding of a mass in the right ventricle attached to the tricuspid valve without valvular dysfunction or outflow tract obstruction. Cardiac magnetic resonance imaging findings were suggestive of myxoma in an infrequent location. We present a case of an 84-year-old woman with systemic arterial hypertension, heart failure with preserved ejection fraction, dyslipidemia, irritable bowel syndrome, and primary hypothyroidism. An abdominopelvic contrasted tomography was performed as a diagnostic workup for abdominal pain, suspecting diverticular disease, with incidental finding of a rounded hypodensity at the tricuspid valve level. She was referred for a transthoracic echocardiogram (TTE). The patient was asymptomatic cardiovascular. Physical examination was unremarkable. The TTE showed a heterogeneous echogenic mass in the right ventricle (RV) attached to the tricuspid valve, partially mobile, without valvular dysfunction or RV outflow obstruction. The transesophageal echocardiogram (Figure 1A–C, Video S1) revealed a heterogeneous mass measuring 19 × 12 mm, mobile, attached to the ventricular face of the anterior tricuspid leaflet, the anterior annulus, the tendon cord, and the anterior papillary muscle, without tricuspid valve regurgitation or stenosis, suggestive of papillary fibroelastoma. Cardiac magnetic resonance (CMR) was performed for further tissue characterization. It revealed a mobile, pediculated, heterogenous mass (17 × 10 mm), attached to the anterior leaflet. The mass appeared predominantly hyperintense on T2-weighted imaging (Figure 1D), isointense on T1-weighted images (Figure 1E), and hypointense with hyperintense foci in steady-state free precession cine sequences (Figure 1F–H). Patchy central contrast enhancement was observed in first-pass perfusion (Video S2), whereas late gadolinium enhancement (LGE) sequences, after gadolinium administration, demonstrated heterogeneous enhancement, suggestive of myxoma (Panel I). The patient and her family decided on conservative treatment with follow-up in the cardiology clinic. A biopsy of the mass was considered unnecessary because the histopathological result probably does not modify the treatment since the mass is most likely benign. Primary cardiac tumors are rare, mostly benign, and most often located in the left atrium. The RV is the more unlikely site of the appearance of a primary cardiac tumor. The most common right-sided primary cardiac tumors in adults include myxomas, papillary fibroblastomas, lipomas, and lymphomas. Right ventricular myxomas are extremely rare (3%–4%) and can produce outflow tract obstruction [1]. TTE is usually the first-line study for evaluating cardiac masses; however, it provides a limited assessment of soft-tissue characteristics. CMR imaging allows anatomical evaluation and tissue characterization using multiparametric sequences which is fundamental to differentiate malignant from benign tumors and among the different benign tumors. Previous studies have reported high diagnostic accuracy of this imaging method for cardiac mass. Mousavi et al. reported that CMR was able to correctly diagnose the type of benign mass in 76%–80% of cases [2], whereas de la Fuente et al. found an accuracy of 100% in detecting myxomas compared with the histopathologic diagnosis [3]. On CMR images, myxomas are typically heterogeneous with variable iso- or hypo-intensity on T1-weighted sequences, hyperintensity on T2-weighted sequences, show heterogeneous enhancement on first-pass perfusion sequences, with iso- or hyperintense areas on LGE sequences [4]. Surgical resection is the treatment of choice, however, it may be expectant if the tumor does not produce valvular dysfunction, obstruction, or embolism, as in this patient. Ethics approval was not required for this article. In this reported case the authors did not describe any personal or confidential information, therefore the IRB did not require consent from the patient. The authors declare no conflicts of interest. The article's data will be shared on reasonable request to the corresponding author. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.