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A Mobile Intracardiac Mass in a Middle-aged Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her mid-40s presented for evaluation of chronic abdominal distension and dyspepsia. The patient had a history of uterine fibroids and a right-sided ovarian cyst for 5 years, but she denied symptoms, including abdominal pain, abnormal defecation, abnormal vaginal bleeding, fever, or weight loss. She had no history of intravenous drug use. A physical examination was notable for jugular venous pulsations and a grade 3/6 systolic murmur best heard at the fifth intercostal space in the left side of the sternum. Laboratory studies revealed normal serum chemistry levels. A complete blood cell count showed a hemoglobin level of 12.7 g/dL (reference, 11.3-15.1 g/dL [to convert to grams per liter, multiply by 10]), a white blood cell count of 7400 cells/μL (reference, 4000-10 000 cells/μL [to convert to cells ×109 per liter, multiply by 0.001]), and a platelet count of 42 × 103 cells/μL (reference, 100 × 103 to 300 × 103 cells/μL [to convert to cells ×109 per liter, multiply by 1.0]). The prothrombin time was 16.5 seconds (reference, 10-14 seconds); activated partial thromboplastin time, 47.5 seconds (reference, 23-35 seconds); fibrinogen level, 52 mg/dL (reference, 185-350 mg/dL [to convert to grams per liter, multiply by 0.01]); and D-dimer, 5190 μg/mL (reference, <590 μg/mL [to convert to nanomoles per liter, multiply by 5.476]). Abdominal ultrasonography showed no abnormalities, but a transthoracic echocardiogram showed a mobile mass located on the tricuspid valve associated with moderate tricuspid regurgitation (Figure 1; Video).

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Cardiac papillary fibroelastoma

B. Perform resection surgery as soon as possible

Transthoracic echocardiography showed that an irregular solid mass with several long branches was attached to the tricuspid valve and highly mobile. The key to diagnosis was a comprehensive analysis of the patient’s medical history, clinical manifestations, laboratory data, and echocardiography findings to distinguish the nature of the mass. The differential diagnosis of a tricuspid valve mass includes a vegetation associated with endocarditis, thrombus, and a metastatic or primary neoplasm. A tricuspid valve vegetation induced by infective endocarditis usually occurs in people using intravenous drugs, with fever, weight loss, and positive blood culture results (choice C). A tricuspid thrombus originating in situ or from venous reflux would present as a solid mass without branches or pedicles. Metastatic tumors (choice A) involving the atrium usually arise from the vena cava and invade the atrial wall; they may also cause pericardial effusion. None of these were present, so we considered a primary tricuspid valve neoplasm.

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Article Information

Corresponding Author: Fei Pei, MD, Department of Cardiovascular Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, No. 157 W Fifth Rd, Xi’an 710004, Shaanxi Province, China (feip_peifx@163.com).

Published Online: October 14, 2020. doi:10.1001/jamacardio.2020.4865

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share her information.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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