imaging characteristics are usually helpful in the differentiation of various cardiac masses with high probability .
the differential diagnosis of aortic thrombus like tumor and vegetation is crucial for avoiding unnecessary surgical intervention .
non - invasive imaging methods would be useful in the diagnosis of suspected cardiac mass , because they may provide earlier diagnosis and more accurate assessment of cardiac mass .
we recently met a patient who had a native aortic valve thrombosis mimicking papillary fibroelastoma .
a 57-year - old female was referred to our hospital because of dyspnea worsening for 2 days . she had no hypertension , diabetes , or prior spontaneous abortion . at presentation , physical examination revealed that arterial pressure was 140/90 mmhg , heart rate was 110 beats / min , and respiration was 20 breaths / min .
mild pitting edema was noted in the right lower extremities . she was found to have both a lupus anticoagulant and antibodies to beta2-glycoprotein i of igg , type .
igg and igm anticardiolipin antibodies , antinuclear antibodies , double - stranded dna antibodies , and venereal disease research laboratory tests were negative .
procoagulant work up including protein c , protein s , antithrombin , urine homocystine assays were normal .
the twelve lead electrocardiogram demonstrated sinus tachycardia and non - specific st - t segments changes in precordial leads .
color doppler and duplex - scan ultrasonography of the lower limbs presented deep venous thrombosis in right common femoral vein , superficial femoral vein , and popliteal vein .
transthoracic echocardiography ( tte ) showed a dilated right ventricle associated with severely depressed systolic function ( supplementary movie 1 and 2 ) . computed tomography ( ct ) with contrast confirmed a diagnosis of pulmonary embolism via the disclosure of clots at the bifurcation of the common pulmonary artery and in its main branches ( fig .
, the aortic valve mass , located at the non - coronary cusp , resembling papillary fibroelastoma was discovered incidentally during chest ct ( fig .
however , the aortic mass was not diagnosed initially with tte due to poor acoustic windows .
four hours later , her vital signs were unstable ; heart rate was 110 beats / min , blood pressure was 90/60 mmhg , and she was breathing at a rate of 26/min . because of persistent right ventricular dysfunction and progressive clinical deterioration , thrombolytic therapy were immediately performed .
after initial treatments , a repeat echocardiography the following day revealed clear improvement in the right ventricular ( rv ) dysfunction with normal rv dimension .
subsequently , a transesophageal echocardiogram ( tee ) was performed for evaluation of the aortic valve , revealing a 1 cm sized mobile cylindrical mass in the aortic valve .
it attached without stalk to the non - coronary cusp annulus of the aortic valve and to extend into the ascending aorta .
the aortic valve was tricuspid , without dystrophic calcification , and had no functional abnormality .
in addition , there was no intracardiac shunt such as patent ductus arteriosus or atrial septal defect .
the aortic valve mass was initially considered as a thrombus according to the presence of deep vein thrombosis and pulmonary embolism .
after 2 weeks anticoagulation , however , a repeat tee revealed that there was still a mass over 1 cm long at the non - coronary cusp of the aortic valve ( fig .
1c and d , supplementary movie 3 and 4 ) . because a size change of the mass was not found after 2 weeks anticoagulation
, we concluded that the aortic valve mass was thought to be a papillary fibroelastoma rather than thrombus.1 ) therefore , surgical resection was considered as the best treatment option in this patient with mobile mass to prevent fatal embolic complications and to confirm pathologic findings .
gross inspection of cardiac mass showed a red - colored gelatinous lobulated mass measuring 1.4  0.9 cm . in the surgeon 's opinion ,
the histology of specimen revealed an organized thrombus with no evidence of papillary fibroelastoma ( fig .
she was diagnosed with antiphospholipid antibody syndrome based on her clinical presentation and laboratory findings .
we repeated the lab tests after 12 weeks , which confirmed the diagnosis of antiphospholipid antibody syndrome .
thrombosis in a native aortic valve is rarely reported and may result in clinically severe complications such as acute myocardial infarction , peripheral ischemia , cardiogenic shock and sudden death.2)3 ) native aortic valve thrombosis may originate in heart valve disease , a hypercoagulative state or an auto - immune disease.4)5 ) antiphospholipid antibody syndrome ( aps ) is an important cause of thromboembolic disease and fetal loss in the general population .
cardiac manifestations in the aps include valvulopathy , coronary artery disease , intracardiac thrombus and pulmonary hypertension.6 ) however , intracardiac thrombus is a rare complication of the aps and can occur in any cardiac chamber.7 ) recent study have reported that the prevalence of intracardiac thrombus was less than 5% in the aps.8 ) differential diagnosis of aortic thrombus like tumor and vegetation is crucial for avoiding unnecessary surgical intervention .
non - invasive imaging methods would be useful in the diagnosis of suspected cardiac mass , because they may provide earlier diagnosis and more accurate assessment of cardiac mass .
recently , advanced imaging techniques improve the sensitivity and specificity.9 ) however , it is usually difficult to differentiate aortic thrombus from tumors , and especially papillary fibroelastoma which is the most common valvular tumor .
most papillary fibroelastomas are asymptomatic , but the lesions are recognized as a cause of embolisms .
echocardiogram usually demonstrates a small , mobile , pedunculated or sessile valvular or endocardial mass , which on many occasions flutters or prolapses into the cardiac chambers during systole or diastole.1 ) as the tumors are small and attached to moving valves , they are usually not seen on ct or magnetic resonance images .
the differential diagnosis of a papillary fibroelastoma includes other cardiac tumors , thrombus and vegetations .
thrombus can be differentiated by an irregular or lobulated shape , laminated apperance , microcavitations and absence of a pedicle.10 ) although imaging tools are continually being developed , they may be clinically challenging to diagnose a cardiac mass .
this case highlights the limitation of imaging tools for cardiac mass to lead a diagnosis . even though , in the presence of the characteristic imaging , clinical decision making with imaging modalities should be performed cautiously .
apical 4-chamber view reveals a markedly dilated right ventricle with depressed systolic function at initial presentation .
short - axis view of transesophageal echocardiogram shows a mass filling the non - coronary sinus of valsalva .
long - axis view of transesophageal echocardiogram at 136 rotation presents a mass just behind the non - coronary cusp .
 the differential diagnosis of cardiac mass is important in determining the therapeutic plan and avoiding unnecessary surgical intervention . 
 non - invasive imaging methods would be useful in the diagnosis of suspected cardiac mass , because they may provide earlier diagnosis and more accurate assessment of cardiac mass . 
 native aortic valve thrombosis is a rare disorder and difficult to differentiate from a tumor , and in particular , a papillary fibroelastoma . 
 thus , the clinical decision making with imaging modalities should be performed cautiously . 
 we recently met a female patient who had a aortic valve mass resembling papillary fibroelastoma in normal native valve . 
 the patient underwent a surgical resection and the pathologic finding showed an organized thrombus with no evidence of papillary fibroelastoma . 
Introduction
Case
Discussion
Supplementary movie legends