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Logo of thijTexas Heart Institute JournalSee also Cardiovascular Diseases Journal in PMCSubscribeSubmissionsTHI Journal Website
Tex Heart Inst J. 2010; 37(5): 612–613.
PMCID: PMC2953232

Gradual Enhancement of a Large Left Atrial Papillary Fibroelastoma on Cardiac Magnetic Resonance

The Waiting Game
Raymond F. Stainback, MD, Section Editor
Department of Adult Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030

A 70-year-old man underwent cardiac magnetic resonance (CMR) after a left atrial mass was discovered on echocardiography. A mobile, 3 × 2.6 × 2.9-cm, T2-bright mass was present at the base of the left atrial appendage, abutting the opening of the left superior pulmonary vein. The mass was not visible either on pre-contrast T1-weighted dark-blood images or on pre-contrast steady-state free precession bright-blood images (Fig. 1). Serial post-contrast imaging revealed very gradual centripetal enhancement (Fig. 2). Because the imaging features were not typical for thrombus, the mass was believed to be a benign tumor, such as a myxoma.

figure 26FF1
Fig. 1 Transaxial cardiac magnetic resonance images through the left atrium (LA), using A) T1-weighted, B) steady-state free precession, and C) T2-weighted imaging. The LA mass is not seen in A or B but is clearly identified in C (arrow).
figure 26FF2
Fig. 2 Transaxial, T1-weighted, inversion-recovery, gradient echo images of the left atrial mass at A) ~30 sec, B) 3 min, C) 7 min, and D) 20 min after gadolinium-based contrast injection. Although A shows no enhancement of the mass, the subsequent ...

The mass was excised. Intraoperative transesophageal echocardiography showed many important features of the mass (Fig. 3). On gross pathology, the mass was gelatinous and friable. Immunohistochemical staining led to the diagnosis of a very large papillary fibroelastoma, the 2nd most common benign primary tumor of the heart (after myxoma).1–4

figure 26FF3
Fig. 3 Static transesophageal echocardiographic diastolic-phase image shows the relationship of the mass (arrow) to the left superior pulmonary vein (PV) and the left atrial appendage (LAA).


Papillary fibroelastomas are usually small (<1 cm) and mobile and are frequently attached to valve leaflets, although they can be found on any endocardial surface. Their enhancement is typically most distinct on CMR, and they usually have a low T2 signal. The risk of embolization necessitates their prompt surgical removal after detection.4,5

Cardiac magnetic resonance is useful for delineating most of the important aspects of masses in or around the heart, including their size, site, and breadth of attachment. It can also delineate their mobility, functional significance, tissue characterization, and enhancement pattern (which usually distinguishes a tumor from thrombus). However, this case reveals 2 important pitfalls of CMR: even large lesions might be stealthy on some pulse sequences, and serial post-contrast imaging might be necessary to determine the presence or absence of enhancement. As a consequence, typical papillary fibroelastomas—as well as other small, mobile masses—might be missed on routine CMR.

Supplementary Material

Video for Fig. 3:


Address for reprints: Michael K. Atalay, MD, PhD, Department of Diagnostic Imaging, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903

E-mail: moc.oohay@99;f5000x#&yalata


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Articles from Texas Heart Institute Journal are provided here courtesy of Texas Heart Institute