Answer: Acute dyspnoea with an unusual mass in the right ventricle

Answer

What is the most likely diagnosis?

1. Infective endocarditis

2. Papillary fibroelastoma

3. Cyanoacrylate embolism

4. Thromboembolism

Explanation

Chest computed tomography angiogram showed dense, bilateral pulmonary embolism compatible with cyanoacrylate remnants which is used to obliterate varices. Cyanoacrylate is a monomer, which polymerizes fast when in contact with blood to form a strong glue. There are already clues to the aetiology of the mass on transthoracic echocardiography (Figure 1 and see Supplementary material online, Videos S1–S4). A history of drug abuse is a risk factor for endocarditis of the tricuspid valve, but vegetations tend to be irregular shaped with myocardial like grey scale. Furthermore, they are typically attached on the low-pressure side of atrioventricular valves. A papillary fibroelastoma is mostly localized downstream and would display a well-demarcated border with digitations but will rarely exceed a size of 3 cm as seen in this case (Figure 1A and B and see Supplementary material online, Videos S1 and S2), making it less plausible.¹ A thrombus is less likely because it is frequently multi-lobulated and hypoechogenic in the acute phase.

Supplementary material

Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.

Funding

None declared.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

Reference

Author notes