left ventricular masses constitute a rare echocardiographic finding in the general population . with careful attention to its location and morphology and appropriate application of clinical information , echocardiography can usually distinguish between the three principal intracardiac mass lesions : tumor , thrombus and vegetation . we report a challenging case of an ambiguous left ventricular apical mass of uncertain nature till histological examination . the anomaly was discovered during an echocardiographic evaluation done because of a recent cerebrovascular ischemic event . a 67-year - old male presented to the emergency room because of a transient confusion episode one week before . physical examination was negligible , whilst the electrocardiogram showed the presence of atrial fibrillation and t wave inversion in v3-v6 leads . non - contrast - enhanced computed tomography ( ct ) scanning of the brain detected a hypodense area within left insular cortex . transthoracic echocardiogram demonstrated a 18  10 mm oval - shaped , homogeneous , echo dense , highly mobile mass floating in left ventricular apex [ figure 1a and b ] . concomitant findings were dilated left atrium without a significant mitral regurgitation , and dilated left ventricle with severely depressed global function ( ef = 25% ) in presence of akinetic apex . the intracardiac mass was characterized by pronounced mobility , lack of an identifiable peduncle ( thus supposed to be faint ) , regular borders without capsule and homogeneous texture similar to myocardium ( closer to the texture of vascularized tissues than to that of fibrotic or thrombotic structures ) . cardiac magnetic resonance imaging ( mri ) excluded contrast enhancement of the mass , anyway its accuracy was limited by reduced temporal resolution in presence of atrial fibrillation and pronounced mass mobility . owing to the embolic risk and the unaltered aspect after seven days of anticoagulant therapy , the patient underwent successful surgical excision through a video assisted port access approach [ figure 1c and d ] . ( c ) trans - mitral mass view deep in left ventricular apex through right thorax heartport approach . ( d ) excised white apical mass with its narrow stalk histopathologic examination identified organized hematic material configuring a white thrombus . recovery was rapid and uncomplicated , optimal medical treatment for heart failure together with oral anticoagulant therapy was administered and well tolerated . pre - discharge control echocardiography on the sixth day revealed a mild recovery in left ventricular function with a 35% ejection fraction , in the absence of apical thrombus recurrence . according to the literature left ventricular apex is a rare site of origin for cardiac tumors , whilst it is most commonly involved in thrombotic stratifications of established cardiomyopathy . confounding elements in the exposed scenario came both from imaging properties of the mass , as from the clinical history of the patient who presented completely asymptomatic from a cardiological standpoint . myxoma is the most common cardiac neoplasm , but it usually arises from interatrial septum presenting with heterogeneous echo - density . high embolic risk and lack of an etiologic diagnosis imposed resection , anyway left ventricle severe contractile dysfunction conferred a high risk profile for a traditional surgical excision through ventriculotomy . the combination of endoscopic views to port access allowed deep transmitralic thrombus visualization and its gentle pull for estraction . the mechanism proposed to account for its development is segmental akinesia of sub - acute subendocardial infarction due to coronary embolization in the context of silent atrial fibrillation in idiopathic cardiomyopathy .
left ventricular apical masses constitute a rare finding . 
 imaging properties together with the clinical history of the patient usually allow an etiologic definition . we report a challenging case of an ambiguous left ventricular apical mass of uncertain nature till histological examination . 
 points of interest were singular clinical history and echocardiographic findings , although not conclusive in hypothesis generating . 
 furthermore to the best of our knowledge , this is one of the rare attempt to excise a deep left ventricular mass with a mini - invasive surgical approach .