Use of microbubble contrast in the diagnosis of a left ventricular papillary fibroelastoma

A papillary fibroelastoma is a rare, avascular, cardiac tumour that is often found incidentally using transthoracic echocardiography (TTE). Peripheral i.v. injection of a microbubble contrast agent is often used to characterize abnormal masses within the heart allowing further delineation of physical features, the area of attachment, and vascularity of the mass in order to differentiate the growth from a tumour or a thrombus. This case highlights a potential pitfall when assessing a cardiac tumour's vascularity using contrast TTE. A cardiac mass was identified on a TTE of a 53-year-old man and was further investigated with microbubble contrast-enhanced TTE. Contrast TTE imaging suggested a vascularized structure in the left ventricle. However, after histological examination the tumour was found to be entirely avascular. LEARNING POINTS: Differentiation of cardiac tumour is usually best performed with contrast echocardiography. Contrast echocardiography may not be best tool to determine if cardiac mass is vascularized. A papillary fibroelastoma can appear vascularized with contrast echocardiography due to it's frond-like structures. Physicians should be aware of this potential confusion when assessing a cardiac tumour in patients.