Hepatocellular carcinoma invading the right atrium: clinical, echographic and angiographic study

The authors report the case of a 54 year old woman suffering from hepatocellular carcinoma with tumor growth into right hepatic vein, inferior vena cava and right atrium. On cardiac examination, a pansystolic bruit and a diastolic rumble were audible at the tricuspid focus. Diagnosis was confirmed by inferior vena cavography and two-dimensional echocardiography, which demonstrated a large mobile mass in the right atrium moving to and fro through the tricuspid valve. This case report emphasizes the value of routine cardiac examination during the course of hepatocellular carcinoma.     

Growth of hepatocellular carcinoma into the right atrium. Report of five cases

Five patients had hepatocellular carcinoma growing into the right atrium. Clinically, all patients had edema in the legs, venous dilatation in the abdominal wall, ascites, and dyspnea. Paroxysmal aggravation of dyspnea and its alleviation by a left decubitus position were noted in three patients. Three patients developed shock after a change in posture. A gallop rhythm in the cardiac murmur was detected in two. Pathologically, all livers had hepatocellular carcinoma and macronodular cirrhosis. At autopsy, a tumor thrombus was found that completely occluded the right hepatic vein and extended into the inferior vena cava and right atrium, partially occluding the inferior vena cava. Antemortem diagnosis of right atrial tumor thrombi in patients with primary hepatocellular carcinoma is difficult, but the condition should be suspected when dyspnea, abnormal cardiac sounds, and shock develop.     

Cardiac lymphoma associated with superior vena caval syndrome and cardiac tamponade: case history

A sixty-three-year-old patient with malignant histiocytic lymphoma of the heart presented with both superior vena cava syndrome and cardiac tamponade. A two-dimensional echocardiogram showed a large tumor mass in the right atrium and pericardial effusion with right ventricular compression. Superior and inferior vena cavagrams disclosed a lobulated tumor located in the right atrium that extended into and obstructed the superior vena cava. After the pericardial effusion was drained and the diagnosis was established, the patient was irradiated and given chemotherapy with resolution of the tamponade and superior vena cava obstruction.     

19例原发性肝癌心脏转移患者超声特征表现和预后分析

目的 总结肝细胞癌(HCC)心脏转移的超声表现特征,并分析其预后。方法 2013年1月～2019年5月我院收治的19例HCC心脏转移患者,回顾分析患者心脏超声表现,总结其特征,并随访其预后。结果 16例(84%)在肝癌相邻的肝静脉内可见实性回声,并延续至下腔静脉和右心房,3例(16%)肝癌相邻下腔静脉内可见实性回声,并延续至右心房;13例(68%)为混合回声,6例(32%)为低回声;15例(79%)边界清晰,16例(84%)形态不规则;19例(100%)右心房癌栓内未见血流信号;12例(63%)右心房癌栓随心动周期活动,活动规律与心动周期无关,7例(37%)右心房癌栓随心动周期活动不明显;3例(16%)累及右室流入道;本组患者发现右心房肿瘤转移后生存时间为25～412天,其中2例患者出现急性肺栓塞。结论 肝静脉-下腔静脉-右心房或下腔静脉-右心房连续性癌栓是本病最重要的超声表现,本病患者生存时间短,可并发急性肺栓塞而死亡。     

The Role of Myocardial Contrast Echocardiography to Assess the Origin of a Mass in Right Cardiac Cavities

We report the case of a patient with hepatocellular carcinoma who was admitted to our hospital with fatigue and edema of lower extremities. Transthoracic echocardiographic examination revealed a mobile echogenic cavoatrial mass that infiltrated the inferior vena cava and extended along the vessel protruding into the right cardiac cavities. The differential diagnosis included a tumor mass originating from the liver and subsequently infiltrating the inferior vena cava and extending into the right cardiac cavities or a large thrombus formed on the tumor mass that infiltrated the inferior vena cava.     

Intravenous leiomyomatosis with extension to the heart: echocardiographic features: a case report

A 40-year-old female was admitted to the hospital for an operation with a presumptive diagnosis of right atrial myxoma. She had had a hysterectomy for leiomyoma 8 months earlier and has since experienced progressive dyspnea on exertion, pedal edema, and two syncope episodes in the past 2 months. Cardiac murmur was detected and two-dimensional echocardiography was arranged. A mobile right atrial mass was discovered, which was thought to be a myxoma. The patient subsequently received open heart surgery. Histologic examination of the resected mass confirmed intravenous leiomyomatosis. Magnetic resonance imaging performed on the eighth postoperative day revealed an intravascular mass from the right common iliac vein to the upper abdominal inferior vena cava. The patient underwent a second operation one and half months after the first operation, with resection of the tumor mass in the inferior vena cava and resection of multiple uterine myoma. She recovered well. Repeat magnetic resonance imaging 6 months following the second operation showed that the inferior vena cava and right atrium were clear of tumor.     

Intracardiac extension of intravenous leiomyoma

Intravenous leiomyoma with intracaval and intracardiac extension is a rare benign neoplasm affecting women. We report a case in which an intravenous leiomyoma originated from the right iliac vein and extended through the inferior vena cava into the right atrium. The correct diagnosis was made intraoperatively, after resection of the intracardiac extension of the tumor, which was 28 cm in length. At the 2nd stage of the operation, a right common iliac venotomy enabled the removal of all residual tumor from the inferior vena cava.     

Two dimensional echocardiography in evaluation of right atrial masses: five cases in pediatric patients

Five unusual cases of a right atrial mass in children are described to illustrate the very valuable contribution that two dimensional echocardiographic examinations can bring to both the initial diagnosis and the subsequent management of patients with these findings. One patient had a large benign hemangioendothelioma of the right atrium. Two infants had extension of a Wilms' tumor from the kidney by way of the inferior vena cava to the right atrium. A fourth patient, an 8 year old girl, had no cardiac disease, and manifested Staphylococcus aureus endocarditis of the tricuspid valve with a large pedunculated mass and subsequent pulmonary embolus. A fifth patient, a premature infant with a central hyperalimentation catheter in the right atrium, had a large thrombus on the catheter that was successfully eradicated with urokinase-induced thrombolysis. Two dimensional echocardiography provides real time imaging of the entire right atrium, interatrial septum, inferior and superior venae cavae and tricuspid orifice and hence is valuable in the diagnosis and management of these clinical problems.     

Inferior Vena Caval and Right Atrial Thrombosis Complicating an Amebic Hepatic Abscess

We describe a 50-yr-old black laborer who presented with right lower chest pain, weight loss, and pedal edema. Ultrasonography and computed tomograms showed a large abscess cavity in the right lobe of the liver which extended very close to the inferior vena cava. The lumen of the adjacent inferior vena cava was partially occluded by thrombus, which could be traced up into the cavity of the right atrium. The hepatic veins were normally patent. Sterile blood-stained pus was aspirated from the abscess. Antibodies against Entamoeba histolytica were present in high titer in the patient's serum. Although propagation of hepatocellular carcinoma into the inferior vena cava and even up into the right atrium is well recognized, inferior vena caval thrombosis extending up into the right atrium has not hitherto been reported as a complication of amebic hepatic abscess.     

Envahissement tumoral extensif des cavités droites et de la veine cave inférieure par un cancer rénal

Renal carcinoma is an aggressive cancer with a high metastatic tendency. It may invade the renal vein, inferior vena cava and potentially extend in some cases to the right heart cavities. We report a case of a 71-year-old male presenting with an impressive polylobular tissular mass inside the right atrium and the right ventricle revealing an aggressive renal carcinoma extending through the inferior vena cava.     

Surgery for hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection without the use of cardiopulmonary bypass

Hepatocellular carcinomas, of which the tumor thrombus extends into the right atrium via the inferior vena cava, may soon cause fatal complications. Only surgery can be an effective treatment. This procedure usually needs the aid of cardiopulmonary bypass. We recently experienced a successful surgery to remove thrombus combined with hepatectomy. Reporting the detailed technique, both associated diagnosis and intraoperative management are discussed herein. We were able to perform hepatectomy of tumor thrombus in the right atrium without the use of cardiopulmonary bypass or veno-venous bypass. The tumor thrombus was removed from the right atrium into the suprahepatic inferior vena cava by reducing the liver on the tail side. And after total hepatic vascular exclusion was achieved, the intracaval tumor thrombus and the right lobe of the liver were removed en bloc. The operation took 545 minutes and the total hepatic vascular exclusion period was 32 minutes. The postoperative course was uneventful. There are some key points for this procedure. Preoperative or intraoperative US is essential in judging whether tumor thrombus can be removed from the right atrium into the inferior vena cava by reducing the liver or not. Test clamping of the inferior vena cava prior to total hepatic vascular exclusion will enable us to judge whether veno-venous bypass during total hepatic vascular exclusion is needed or not. Surgery without the use of cardiopulmonary bypass is safe and can be minimally invasive when it is performed with a reliable diagnosis and technique.     

Kidney tumour mimicking cardiac mass

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.     

Cardiac myxoma arising from the inferior vena cava

A cardiac myxoma that arises from the inferior vena cava (an extremely rare finding) may interfere with caval cannulation. In such cases venous cannulation for cardiopulmonary bypass has been performed directly into the inferior vena cava or through the femoral vein. We present a case in which routine cannulation through the right atrium proved safe and gave good exposure for complete resection of the tumoral mass.     

An approach to intrapericardial inferior vena cava through the abdominal cavity, without median sternotomy, for total hepatic vascular exclusion.

In surgical resection for hepatocellular carcinoma with tumor thrombus extending into the inferior vena cava and other malignancies involving the retrohepatic inferior vena cava, the usefulness of total hepatic vascular exclusion has been reported by several authors. Total hepatic vascular exclusion usually consists of clamping at three points; at the infrahepatic inferior vena cava, at the suprahepatic inferior vena cava, and in Pringles' maneuver. Tumor thrombus extending into the inferior vena cava at the intrapericardial level below the right atrium can be resected without the use of cardio-pulmonary bypass. The inferior vena cava at the intrapericardial level has been reported to be usually approached by median sternotomy such as Chevron incision. We herein demonstrate an approach to the intrapericardial inferior vena cava through the abdominal cavity without median sternotomy.     

Budd-Chiari syndrome as the primary manifestation of a fibrolamellar hepatocellular carcinoma.

An 18-year-old female patient was admitted with ascites, right upper abdominal tenderness and peripheral edema. Angiography showed complete occlusion of the vena cava inferior up to the level of the right atrium. By open heart surgery, masses of thrombotic material were pulled out of the v. cava inferior/vv. iliacae which histologically contained tumor cell populations consistent with a hepatocellular carcinoma. Celiacography showed a highly vascularized tumor in the right hepatic lobe. Histologically, it proved to be fibrolamellar subtype hepatocellular carcinoma.     

Intravenous leiomyomatosis: A rare cause of intracardiac mass

Intravenous leiomyomatosis is an unusual clinical condition characterized by histologically benign smooth muscle lesions extending from the uterus into pelvic and systemic veins and, more rarely, into the right cardiac chambers. We report the case of a 45-year-old woman who presented with a three-week history of dyspnea on exertion, shortness of breath and fatigue. Echocardiography showed a large mobile mass in the right atrium prolapsing into the right ventricle and extending to the inferior vena cava. A computed tomography scan revealed a large mass extending from the right atrium to the inferior vena cava and through the systemic veins as far as the popliteal veins. A presumptive diagnosis of large thrombus was made; the correct diagnosis of intravenous leiomyomatosis with intracardiac involvement was obtained only after surgical resection and histologic examination.     

Successful resection of renal cell carcinoma with tumor thrombi extending into the right atrium: a case report.

Renal cell carcinoma (RCC) is often associated with an extension of tumor thrombi into the inferior vena cava (IVC) and occasionally up to the right atrium. RCC with IVC involvement has a relatively favorable prognosis when it is completely resected. We present a successfully resected case of RCC with tumor thrombi extending into the right atrium. We performed radical right nephrectomy with lymph node dissection and removed the tumor thrombi en bloc under total hepatic vascular exclusion with the veno-venous bypass between the IVC and the right atrium using an active centrifugal force pump. The patient has been in good condition for 3 years since surgery with no evidence of recurrence.     

Asymptomatic membranous obstruction of the inferior vena cava forming intrahepatic collateral pathways

Intrahepatic and/or extrahepatic collateral pathways result from the membranous obstruction of the inferior vena cava. These collaterals are usually insufficient to prevent Budd-Chiari syndrome. We reprot an unusual case of asymptomatic membranous obstruction of the inferior vena cava in which marked intrahepatic collateral pathways were formed. Although the inferior vena cava terminated above the orifice of the right hepatic vein, the middle and left hepatic veins were patent above the membrane, without narrowing. Blood from the inferior vena cava drained into the right atrium via the intrahepatic collaterals between the right and middle hepatic veins without resistance.     

Use of contrast echocardiography in diagnosis of anomalous connection of right superior vena cava to left atrium.

A 4-month-old infant with cyanosis but without other abnormal cardiac findings is presented in whom the diagnosis of anomalous systemic venous connection to the left atrium was made by contrast echocardiography. The diagnosis was later confirmed by cardiac catheterisation and selective cineangiography. When saline was injected into a vein on the dorsum of each hand while echocardiographically recording the cardiac structures, the left atrium, left ventricle, and aorta were opacified without visualisation of the right ventricle. Similar study with injection into the right foot produced opacification of the right ventricle without visualisation of the left-sided structures. These data suggested normal drainage of the inferior vena cava with anomalous connection of the superior vena cava to the left atrium. A review of the previously reported cases of anomalous connection of the right superior vena cava to the left atrium is presented together with the possible embryological origin of this anomaly.