Severe Right Atrial Obstruction Due to Cardiac Extension of a Hepatic Carcinoma

Abstract

A 73-year-old patient with a past medical history of hepatitis C and hepatocellular carcinoma, treated by chemo-embolization 3 years ago, presented with severe exertional dyspnea, orthopnea, and edema of the lower extremities. By that time the patient was hypotensive and tachycardic. Two-dimensional echocardiography disclosed a sizeable mass located in the right atrium. This finding was further investigated and confirmed by magnetic imaging of the heart, which demonstrated a 9 × 6 cm right atrial mass, extending from the liver through the inferior vena cava. The white arrow in Figure 1 points to the hepatic tumor, which extends to the right atrium. The patient was operated on urgently because of hemodynamic deterioration. Cardiopulmonary bypass was established through a median sternotomy, with cannulation of the ascending aorta, as well as the superior vena cava and right femoral vein for drainage. Cardioplegia was given and the aorta was cross clamped. A right atriotomy was performed under deep hypothermic (18°C) circulatory arrest to obtain a bloodless operative field (Fig 2), to reduce operative risk, and to allow for maximal tumor resection. This technique was first described by Ein and colleagues [1Ein S.H. Shandling B. Williams W.G. Trusler G. Major hepatic tumor resection using profound hypothermia and circulatory arrest.J Ped Surg. 1981; 16: 339-342Abstract Full Text PDF PubMed Scopus (43) Google Scholar] for surgical treatment of hepatic tumors with intravascular extension. In our case, the tumor was not invading the atrial wall, and it could be removed up to the hepatic veins. Figure 3 shows the resected hepatic tumor. Operation resulted in immediate relief of venous obstruction and symptomatic relief.Fig 3View Large Image Figure ViewerDownload (PPT) Intracardiac extension of hepatocellular carcinoma is rarely encountered. The prognosis is poor. Palliative resection may be mandated by hemodynamic compromise.