differential diagnosis of an intracardiac mass in the tricuspid valve after valvular surgery includes thrombosis , tumor , and vegetation , among others . normal tissue such as fatty material and pectinate muscle surrounding the tricuspid annulus also may appear as a pseudo - tumor.1 ) in our case , because the patient had undergone annuloplasty , thrombosis was suspected as most likely and therefore thrombolytic therapy was instituted.2 ) because the size of the cardiac mass did not change , however , we finally chose a surgical method and the mass was found to be a myxoma . to our knowledge , this is first reported case of tricuspid valve myxoma in korea . in november 2009 , a 55-year - old man ( who had smoking as a risk factor ) was admitted to the hospital with progressive resting dyspnea . on physical examination , initial laboratory work - up , including complete blood count , liver function tests , and cardiac enzyme level determination did not reveal any abnormality . he had an abnormal chest radiograph which showed cardiomegaly and a marked pulmonary trunk , and electrocardiogram reflected right ventricular strain pattern with normal sinus rhythm ( fig . 1 ) . nt - pro bnp level was 5,592 pg / ml ( normal : < 198 pg / ml ) , and d - dimer level was 2,296 ng / ml ( normal : < 500 ng / ml ) . transthoracic echocardiography ( tte ) revealed right cardiac dysfunction with elevated right ventricular systolic pressure ( rvsp ) . pulmonary embolism was suspected and chest 3-dimensional computed tomography ( 3d ct ) with contrast enhanced for pulmonary embolism showed a massive pulmonary thromboembolism ( fig . 2 ) . no deep vein thrombosis in venous doppler for the lower extremities or hypercoagulability in the laboratory test was apparent . although the patient was hemodynamically stable , hypoxemia was noticed in arterial blood gas analysis ( ph = 7.493 , pco2 = 27.9 mm hg , po2 = 61.9 mm hg ) . therefore he was thrombolysed with recombinant tissue plasminogen activator and experienced a rapid improvement in oxygenation.3 ) as follow - up , a second echocardiography and chest 3d ct was performed 7 days later . tte showed impairment in right ventricular function even though rvsp was reduced from 119 to 96 mm hg and a second ct showed a partially resolved status . 3 ) . because further treatment was required to reduce pulmonary hypertension , we performed open pulmonary embolectomy with removal of thrombus from both pulmonary arteries , and de vega 's tricuspid annuloplasty to correct severe tricuspid valve regurgitation . the patient experienced no postoperative complications and made a satisfactory recovery . at 2 weeks after surgery , his tte findings showed improvement in right heart function and rvsp ( 97  47 mm hg ) . nine months later , however , we found a mobile echogenic intra - cardiac mass ( 1.49  2.2 cm sized ) at follow - up . the mass was attached to the septo - posterior leaflet portion of the tricuspid valve and protruded to the ventricular side . for differential diagnosis , trans - esophageal echocardiography was carried out and revealed a mobile mass attached to the annuloplasty groove ( fig . also his prothrombin time was occasionally inappropriate fluctuating from 1.58 to 2.65 for 9 months . based on a suspicion of thrombus formation , we decided to do thrombolysis with tissue plasminogen activator ( tpa ) . tpa ( alteplase ) was infused 100 mg , 10 mg as a bolus and 40 mg over 2 hours followed by 50 mg over 5 hours.2 ) however , the mass did not respond to thrombolysis , and the patient underwent surgery . gross examination of the operative specimen revealed a polypoid mass with smooth surfaces ; histological examination showed a myxoid matrix composed of an acid - mucopolysaccharide - rich stroma and embedded polygonal cells in hematoxylin and eosin stain , consistent with myxoma ( fig . thrombosis is first suspected when an intracardiac mass is observed in the tricuspid valve after valvular surgery . patients with a right atrial thrombus have several therapeutic options . for the patient at high risk for surgery , anticoagulation with heparin followed by an ongoing regimen of warfarin may be the treatment of choice.4 ) thrombolytic therapy is also reported to be successful in some patients,5 ) although the possibility of pulmonary embolism caused by a fragmented thrombus due to thrombolytic therapy is a serious concern . in our case , given the patient 's previous history of valvuloplasty , the valvular mass shown in tte was suspected to be thrombus , so thrombolytic therapy was performed.2 ) after thrombolytic therapy , the size of the valvular mass did not change . we needed to exclude the possibility of other types of cardiac tumor and therefore decided to examine by surgical excision . the differential diagnoses of intraatrial masses include atrial myxoma , thrombus related to atrial fibrillation , vegetation , metastatic tumors , and primary benign or malignant tumors.6 ) although a mass usually shows up differently in an echocardiographic image , it is difficult to discriminate between thrombus and tumor . however , in our case it was difficult to make an accurate preoperative diagnosis . myxomas are the most common type of primary benign cardiac tumor , accounting for 50% of all primary cardiac tumors . myxomas may develop in any chamber of the heart : approximately 75% of myxomas develop in the left atrium , 23% in the right atrium , and the remaining 2% in the ventricles . when they do occur , they are usually slow - growing fibroelastomas which manifest after several years.7 ) the interesting aspect of our case was the rapid growing cardiac myxoma which became apparent on the tricuspid valve within 9 months after tricuspid annuoplasty . to our knowledge , this is first reported case of tricuspid valve myxoma in korea .
a 55-year - old man with massive pulmonary thromboembolism underwent thrombolysis , pulmonary artery embolectomy and tricuspid annuloplasty . 
 nine months later , a mobile echogenic intra - cardiac mass was found in the tricuspid valve . because the patient had undergone annuloplasty , thrombosis was suspected as the most likely diagnosis and thrombolytic therapy was instituted . 
 however , the size of the cardiac mass did not change and after surgical excision the mass was found to be a myxoma . 
 cardiac valvular tumors are uncommon and when they occur they are usually slow growing fibroelastomas . in this case , the rapid growing cardiac myxoma on the tricuspid valve was found after the occurrence of pulmonary thromboembolism . to our knowledge , this is first reported case of tricuspid valve myxoma in korea .