Papillary fibroelastoma prolapsing into the left ventricular outflow tract: diagnosis using three-dimensional TEE

A 72-year-old woman was admitted to our hospital with exertional dyspnea and atrial tachycardia due to atypical atrial flutter. Comprehensive three-dimensional transesophageal echocardiography (3D-TEE) with offline reconstruction of the dataset (Siemens Foursight TEE, Erlangen, Germany) allowed visualization of the origin of the tumor and gave important additional information about the tumor: the tumor surface was floppy, it had the appearance of a "sea anemone", and it was attached to the endocardium of the head of the papillary muscle by a short stalk. The tumor was assessed to be 1.9 × 1.4 × 0.9 cm, and a prolapsing of the tumor into the left ventricular outflow tract during systole was demonstrated.A tumor size of 8 × 10 mm and an infiltration of the head of the anterior papillary muscle were found during surgery. The histopathological findings were typical for a papillary fibroelastoma (PFE) with involvement of the head of the papillary muscle.Our case indicates that a PFE might be difficult to distinguish from myxoma by echocardiography. Thus, the multimodal imaging approach and the three-dimensional visualization of the surface, the localization, and the attachment of the tumor to the head of a papillary muscle were very helpful for the identification of a fibroelastoma in this particular case.