Robotic Resection of a Papillary Fibroelastoma Arising From the Coumadin Ridge: A Multimodality Imaging of an Echocardiographic Blind Spot

Papillary fibroelastomas (PFEs) are rare, benign cardiac tumors that carry a significant risk of cardioembolism. While transthoracic echocardiography (TTE) is the standard initial screening tool, certain anatomical locations, such as the coumadin ridge, can present diagnostic challenges. We report the case of a PFE located in an echocardiographic "blind spot" that required a multimodality imaging approach for diagnosis and surgical planning. A 61-year-old woman was referred to our hospital after a 5-mm mass near the left atrial appendage was incidentally detected on cardiac computed tomography angiography (CCTA). The patient had no history of embolic events. Notably, standard TTE failed to visualize the mass. A comprehensive multimodality assessment was performed: transesophageal echocardiography (TEE) revealed a highly mobile mass attached to the coumadin ridge with moderate mitral regurgitation; CCTA clarified the anatomical relationship; and cardiac magnetic resonance imaging findings were more consistent with a tumor than a thrombus. Given the high embolic risk posed by the tumor's mobility, a robotic minimally invasive resection and mitral repair was performed. The tumor was successfully excised without complications, and histopathology confirmed a PFE. This case highlights the limitations of TTE in evaluating the coumadin ridge and underscores the indispensability of multimodality imaging for characterizing small, mobile cardiac tumors located in anatomical blind spots. Robotic surgery offers a safe and effective minimally invasive treatment option for preventing embolic complications in such cases.