Case presentation
A 60 years old woman with history of dyspnea on exertion from 2 years ago presented to the Tehran Heart Center[3]. After initial evaluations in trans-thoracic echocardiography (TTE) severe mitral stenosis with score Wilkins[4] score 7 was diagnosed. She was planned to undergo TEE for further evaluation and probable PTMC in this admission. She was on Inderal 20 daily from 6 months ago and furosemide 20 daily was added recently due to her dyspnea. TEE was done without complication after local anesthesia with 1.5 mg midazolam. Severe MS was seen and low LAA velocity (28.2 cm/s) was noted, Figure 1; Panel A. Suspicious mass was seen near LAA and was first consumed to be a LAA thrombosis. After more angulations of the probe and other off-axis views it was considered as a well- defined mass-like lesion in TS, Figure 1; Panel B; measuring 2.35 cm*2.65 cm, Figure 1; Panel C. In this figure, one can also notice thick epicardial fat pad. The Echogenisity of lesion within TS is exactly like the epicardial fat around right ventricle (RV), Figure 1, Panel C thin arrow.
Three-dimension mapping was performed with live 3D wide angled full volume TEE. Echogenicity and features of the lesion was against thrombosis and was in favor of fat tissue, Figure 1; Panel D. Hence, TSFP was diagnoses. Videos of 3D and 2D TEE imaging has been attached as a supplementary file.