Clinical Realities of Multimodal Imaging in Papillary Fibroelastoma in 385 Pathology-Proven Cases

OBJECTIVES: To evaluate the diagnostic utility of computed tomography (CT) and cardiac magnetic resonance (CMR) imaging compared to transesophageal echo (TEE) in detecting cardiac papillary fibroelastomas (PFE), using the largest dataset of pathologically-confirmed cases to date, and characterize imaging findings across modalities. PATIENTS AND METHODS: We retrospectively reviewed 385 patients with pathologically proven PFEs identified during cardiac surgery from January 1, 1998, through December 31, 2024. We assessed TEE, CT and CMR for lesion detection and imaging characteristics. The study was approved by the Mayo Clinic Institutional Review Board (IRB 23-009539). RESULTS: Of 384 patients who underwent TEE, PFEs were detected in 310 (80.7%; 95% CI, 76.5%-84.4%). CMR detected PFEs in 11 of 48 patients (22.9%; 95% CI, 13.0%-36.1%), whereas CT detected PFEs in 39 of 91 patients (42.9%; 95% CI, 33%-53%), predominantly left-sided, especially on the aortic valve. Detection was higher when CT or CMR was performed specifically for cardiac mass evaluation (80.0% and 88.9%, respectively) than for other indications. All CT and CMR-detected PFEs were also seen on TEE. TEE demonstrated the ability to detect very small lesions, including PFEs measuring less than 1 mm. CONCLUSION: TEE remains the primary imaging modality for suspected PFEs. CT and CMR provide complementary information when TEE is contraindicated or inconclusive, but detection varies with study indication, protocol, lesion characteristics, and prior knowledge of lesion location. A targeted multimodality approach may improve diagnostic confidence in selected cases.