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Ann Thorac Surg 2001;72:931-933
© 2001 The Society of Thoracic Surgeons

Case report

Urgent heart surgery for an atrial mass: metastatic hepatocellular carcinoma

Michael W. Chu, MDa, Ayman Aboguddah, MDb, Peter A. Kraus, MDb, Leith R. Dewar, MDa

a Division of Cardiovascular and Thoracic Surgery, Regina General Hospital, Regina, Saskatchewan, Canada
b Department of Medicine, Regina General Hospital, Regina, Saskatchewan, Canada

Accepted for publication August 17, 2000.

Address reprint requests to Dr Dewar, Medical Office Wing, Regina General Hospital, 1440 14th Ave, Regina, Saskatchewan S4P 0W5, Canada
e-mail: lrsdewar{at}sk.sympatico.ca


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Etension of metastatic hepatocellular carcinoma into the right atrium is exceedingly rare and has a very poor prognosis. We report a case of successful surgical excision of hepatic tumor extension into the right atrium that was causing hemodynamic compromise.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Metastatic hepatocellular carcinoma has a very poor prognosis. Without treatment, the mean survival of a patient with hepatocellular carcinoma can be calculated within months from diagnosis. With surgical treatment of resectable lesions, the 5-year survival rate ranges from 12% to 39% [1]. Rarely when a hepatoma invades the hepatic veins, inferior vena cava and subsequently the right atrium, the outcome is usually poor. Patients who present with right atrial tumor extension are often misdiagnosed [2]; however, even with correct diagnosis, effective treatment has not been well established. Palliative resection of the right atrial mass may be necessary owing to hemodynamic compromise. Our success in urgently resecting a right atrial hepatocellular tumor thrombus causing cardiovascular instability is reported.

A 71-year-old man with known metastatic hepatocellular carcinoma secondary to alcoholic cirrhosis presented with severe, progressive dyspnea, orthopnea, and paroxysmal nocturnal dyspnea for more than 1 week. Before this he had excellent exercise tolerance and denied any history of heart or lung disease. Three years earlier, he presented to another institution with an acute abdomen and was found to have a ruptured hepatoma at laparotomy. A partial right lobectomy was carried out for control of hemorrhage. Extensive tumor seeding of the peritoneal cavity resulted from the ruptured hepatoma. Postoperatively, the remaining liver lesions were treated with lipoidil and chemoembolization. After the palliative therapy, the patient was asymptomatic and the remaining hepatomas were found to be stable on serial computerized tomography (CT) scans of the abdomen; multiple peritoneal and omental masses were also observed with serial CT scans and assessed to be unchanged.

On examination, the patient was hypotensive and tachycardic. Despite 100% oxygen by nonrebreather mask, his oxygen saturation was 88%. A grade II/VI holosystolic murmur was heard at the left lower sternal border. A large, easily reducible ventral hernia was palpated. There were spider nevi and palmar erythema but no signs of acute liver failure were observed. The complete blood count, platelets, and the coagulation profile were within normal limits. Liver enzymes and bilirubin were slightly elevated; however, {alpha}-fetoprotein was within normal limits. Chest roentgenogram showed mild cardiomegaly and 12-lead electrocardiogram was normal. The presumptive diagnosis of pulmonary embolism was made; however, ventilation-perfusion scanning indicated a low probability of pulmonary embolism. A CT scan of the abdomen showed liver lesions and peritoneal metastasis unchanged from previous, judging by CT reports. Transthoracic echocardiogram revealed a 5 x 5 cm mass almost completely filling the right atrium that originated from the inferior vena cava (Fig 1). The mass was causing a functional tricuspid stenosis by occluding the tricuspid annulus. A patent foramen ovale was identified. The patient’s cardiac output was dependent on the patent foramen ovale with right to left shunting seen on echocardiogram. Because of hemodynamic compromise, the decision to proceed with palliative resection was made.



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  		Fig 1. Two-dimensional transesophageal echocardiogram showing a large, mobile and pedunculated thrombus in the right atrium. (M = metastatic hepatocellular tumor thrombus; PFO = patent foramen ovale; SVC = superior vena cava.)

 
The operation was carried out through a standard median sternotomy. The aortic cannula was placed in usual fashion in the ascending aorta. The superior vena cava, which externally was free of tumor, was cannulated with a right-angled venous cannula. Because of extensive inferior vena cava tumor extension, the right groin was exposed and a venous cannula was placed in the right femoral vein. Cardiopulmonary bypass commenced and cold antegrade cardioplegia was given for myocardial protection. The patient was cooled to 24°C for hypothermic circulatory arrest. The right atrium was opened (Fig 2) and the mass was extensively resected with a deep pedicle remaining in the right hepatic vein. A small patent foramen ovale was identified and oversewn before closure of the atriotomy. Systemic perfusion was reinstituted after 17 minutes of circulatory arrest. While rewarming, the large ventral hernial sac was resected and the hernia was primarily closed without tension. Cardiopulmonary bypass was discontinued after 61 minutes, and the chest was closed in regular fashion. Although coagulation studies met the biochemical criteria for mild disseminated intravascular coagulopathy, intraoperative bleeding was not a significant problem. Pathology confirmed the diagnosis of metastatic hepatocellular carcinoma in the right atrial mass as well as the resected hernial sac. The postoperative course was uneventful except for atrial fibrillation, which was managed with oral sotalol; the patient was discharged home 15 days after the operation. At 6 week follow-up, the patient continued to do well and denied any symptoms of liver failure or worsening metastatic disease.



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  		Fig 2. Intraoperative photograph of the right atrial tumor thrombus. (M = metastatic hepatocellular tumor thrombus.)

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
We describe a case of metastatic hepatocellular carcinoma with direct tumor extension to the right atrium. There are only a handful of previously described cases, most coming from Japan, with few from North America. Diagnosis is difficult because of the vague symptoms and signs and also the rarity of this type of metastatic hepatocellular carcinoma [2–4]. Echocardiography is not only crucial for diagnosis but also for preoperative planning [2, 3]. It is important to know the tumor location before bicaval cannulation to prevent fragmentation and embolization of the tumor. If feasible, intraoperative transesophageal echocardiography has been suggested to help guide safe venous cannulation and excision of right atrial masses [5].

This patient had a very poor preoperative prognosis; however, in light of hemodynamic compromise, reasonable liver function, and the patient’s clear understanding of the situation, the decision to carry out palliative resection was made. Complete resection of the right atrial thrombus combined with resection of the primary liver lesion has been described [6, 7]. However in this case, numerous hepatic lesions and extensive peritoneal metastasis prevented any attempt at complete tumor resection. At operation, superior vena cava and femoral vein cannulation were carried out because of an occlusive mass in the inferior vena cava. Hypothermic circulatory arrest was instituted to facilitate exposure and minimize tumor cell embolization to the patient. According to our literature search, circulatory arrest has only been described once before [3]. More commonly, veno-venous bypass with hepatic exclusion technique is being used [6, 7].

Our experience demonstrates that metastatic hepatocellular tumor extension into the right atrium can be successfully carried out with minimal morbidity and can produce a satisfactory outcome for the patient.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Farmer D.G., Rosove M.H., Shaked A., Busuttil R.W. Current treatment modalities for hepatocellular carcinoma. Ann Surg 1994;219:236-247.[Medline]
  2. Lynch M., Clements S.D., Shanewise J.S., Chen C.C., Martin R.P. Right-sided cardiac tumors detected by transesophageal echocardiography and its usefulness in differentiating the benign from the malignant ones. Am J Cardiol 1997;79:781-784.[Medline]
  3. Miller D.L., Katz N.M., Pallas R.S. Hepatoma presenting as a right atrial mass. Am Heart J 1987;114:906-908.[Medline]
  4. Ehrich D.A., Widmann J.J., Berger R.L., Abelmann W.H. Intracavitary cardiac extension of hepatoma. Ann Thorac Surg 1975;19:206-211.[Abstract]
  5. Rousou J.A., Tighe D.A., Rifkin, et al. Echocardiography allows safer venous cannulation during excision of large right atrial masses. Ann Thorac Surg 1998;65:403-406.[Abstract/Free Full Text]
  6. Iemura J., Aoshima M., Ishigami N., Kaneda T., Oba N. Surgery for hepatocellular carcinoma with tumor thrombus in the right atrium. Hepato-Gastroenterology 1997;44:824-825.[Medline]
  7. Fujisaki M., Kurihara E., Kikuchi K., Nishikawa K., Uematsu Y. Hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection with the use of cardiopulmonary bypass. Surgery 1991;109:214-219.[Medline]



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