Prominent Papillary Muscle or Papillary Fibroelastoma, Apically displaced papillary muscles,Solitary Papillary Muscle Hypertrophy

A 55 years old female , brought to the Echo Lab for perioperative assessment of non-cardiac surgery of the heart . She was known patient of hypertension , DM type 2 with normal physical examination . During echocardiography we found a mass in LV cavity ECG was normal with no axis deviation , and hypertrophy pattern . There was Cardiologist to cardiologist difference of opension about below answers of diagnosis of the following echocardiogram :

1- Prominent Papillary muscle .

2- Papillary Fibroblastoma 

3- Apically displaced anterolateral papillary muscle .

4-  Solitary Papillary Muscle Hypertrophy.

The apically displaced anterolateral papillary muscle was definedwhen the base of the papillary muscle was located at the apical one-third of the left ventricle.

An abnormal insertion of the papillary muscle was noted in some patients with ADPM. Some patients had papillary muscle inserted into the base of a mitral leaflet or directly into the LVOT.

Apical hypertrophic cardiomyopathy (ApHCM) is a subtype ofmhypertrophic cardiomyopathy (HCM), which is more frequently mfound in Asians than in Caucasians.Although it has been demonstrated that ApHCM is generally benign, cardiovascular complications are not uncommon and therefore, correct diagnosis of mthis entity is important. Twelve-lead electrocardiograms (ECGs) of ApHCM are characterized by a giant negative T (GNT) wave in precordial leads. Moreover, the depth of the GNT wave has been reported to be associated with the severity of apical thickening or with the ratio of apical-to-basal myocardial thickness. Therefore, in the presence of a GNT wave, a diagnosis of ApHCM has often been made in patients with apical hypertrophy, especially when the GNT wave cannot be explained otherwiseThe phenomenon of solitary papillary muscle hypertrophy is rare with only 2 references in the literature. Furthermore, giant negative T and U waves are 2 common electrocardiographic phenomena in hypertrophic cardiomyopathy and have been attributed to hypertrophy of the posterior papillary muscle. Solitary hypertrophy of the anterior papillary muscle might be a new echo-electrocardiographic syndrome.

Electrocardiogram and its images of apical hypertrophy. (A) T wave negativity more prominent in the mid-precordial than in the lateral precordial leads represent classic electrocardiographic finding in apical hypertrophy. (B) Representative echocardiography images of the classic pattern of apical hypertrophic cardiomyopathy showing an ‘ace of spade’ shape during diastole. (C) However, it is not unusual to encounter an atypical pattern of hypertrophy showing more prominent hypertrophy at the apical lateral than at the apical septal segments.

Various patterns of anterolateral papillary muscle location in the apical four-chamber view. (A) Normally located papillary muscle . (B) Apically displaced papillary muscle . (C) Variation in the morphology of papillary muscle head attached to the left ventricular (LV) . (D) Apically attached accessory papillary muscle. (E) The papillary muscle inserted into the base of a mitral valve leaflet . (F) The papillary muscle inserted into the left ventricular outflow tract . An apicoseptal segment may also show certain degree of hypertrophy, but for the clarity of presentation, this finding is not represented in above fig.

Anothoer distinc feature of papillary muscle is Papillary fibroelastoma, or papilloma, is a benign intracardiac tumor with a characteristic appearance on echocardiograms. It is usually small (average size, <15 mm) and has a characteristic stippled edge, with a shimmering appearance at the tumor-blood interface. There are f ingerlike projections consistent with the fronds that are described pathologically as a “sea anemone.” The most frequent location is the aortic valve on either the aortic or ventricular surface, followed by either the atrial or ventricular surface of the mitral valve.138 Papillomas can be found in any chamber or on any surface and are usually single, but multiple tumors occur in approximately 10% of patients.

Solitary Papillary Muscle Hypertrophy: Transthoracic, two-dimensional echocardiography revealed isolated hypertrophy of the anterolateral papillary muscle, with an otherwise normal left ventricle with no hypertrophy in any other segment( image below) .  

The answer is A. Prominent Papillary Muscle .