by Maria Viviana Carlino1,2 MD; Costantino Mancusi1 MD; Alfonso Sforza1,2 MD; Giorgio Bosso2 MD; Valentina Di Fronzo2 MD; Gaetana Ferro2 MD; Giovanni de Simone1 Prof.; Fiorella Paladino2 MD
(1) Hypertension Research Center, UOC Emergency Medicine, Federico II University Hospital, Naples.
(2) Emergency Department, Cardarelli Hospital, Naples.
Download article PDF – POCUS Journal 2017; 2(3):20-21.
A 74-year-old woman with history of hypertension presented to the Emergency Department (ED) with severe resting dyspnea and swelling in the feet, ankles and legs. She was on treatment with furosemide and a beta blocker. At the time of admission blood pressure was 145/88 mmHg, heart rate (HR) 99 bpm, regular, oxygen saturation was 89% (FiO2 21%) and respiratory rate was 17 breaths/min. Chest auscultation revealed no significant abnormality. Cardiovascular examination revealed normal cardiac rhythm and extremities’ pitting edema. The ECG exhibited sinus rhythm (HR=99 bpm), right bundle branch block (RBB) and left anterior fascicular block (LAFB).
Blood tests revealed leukocytosis of 13,900 cells per mm3, N-Terminal pro-Brain Natriuretic peptide (NT-pro-BNP) level of 23336 pg/mL (normal, < 125 pg/mL), international normalized ratio of 1.59, bilirubin level of 3.12 mg/dL (normal, < 1.2 mg/dL), Aspartate aminotransferase (AST/GOT) level was 71 UI/L (normal, <40), Glomerular Filtration Rate (GFR) was 54.32 mL/min/1.73 m2 and electrolytes were within normal parameters. The patients denied previous viral hepatitis or other liver disease. Chest radiography appeared normal.
Point-of-care ultrasound (POCUS) with pocket size device was done upon arrival in ED (Video 1-1a-2).
Video S1. Apical 4-chamber view and (a) apical 4-chamber view with color doppler.
Video S2. Point-of-care abdominal ultrasound view
On POCUS the parasternal long axis view showed left ventricle normal in size and function. From Apical 4-chamber view a large mass in the right atrium (RA) extending to or originating from the inferior vena cava (IVC) (Video 1) was found with clear impairment of tricuspid valve function (Video 1a). Point-of-care abdominal ultrasound revealed a hepatic lesion extending in the IVC (Figure 1- Featured Image, Video 2) and into the RA. Lung ultrasound showed predominantly A-Profile bilaterally.
The patient underwent Contrast-enhanced CT scan of abdomen and thorax that showed a large liver lesion (15x12x12 cm) suggestive of Hepatocellular Carcinoma (HCC) extending into IVC and RA and multiple right lung segmental perfusion defects (Figure 2).
Our diagnosis was: pulmonary microembolism due to neoplastic mass infiltrating the inferior vena cava and the right atrium.
Among cardiac masses secondary tumors are a hundred times more common than primary cardiac lesions and they are, usually, located in the right side of the heart . Metastasis may reach the heart via the lymphatic or hematogenous route, or by direct or transvenous extension . Hepatocellular carcinoma accounts for 1-2.5% of all cancer in America with extension to inferior vena cava and right atrium in 1-4% of the cases .
Symptom presentations for cardiac tumors is quite varied, but it is dependent upon tumor location and size, rather than upon histologic characteristics. Presentation includes congestive heart failure from intracardiac obstruction, systemic or pulmonary embolization, constitutional symptoms, and arrhythmias .
Rarely, right atrial tumors or large thrombi in the right atrium can mimic tricuspid stenosis (TS) obstructing the right ventricular inflow tract as in our patient .
NT-proBNP is a quantitative marker of Heart Failure (HF) affected by both systolic and diastolic left ventricular (LV) dysfunction, but markedly elevated NT-proBNP is, also common in cancer patients . In patients with right ventricular (RV) pressure overload due to primary pulmonary hypertension and thromboembolism, plasma BNP levels correlate with mean pulmonary artery pressure, right atrial pressure, RV end-diastolic pressure, and total pulmonary resistance . Thus, it is conceivable that elevated levels of NT-proBNP in our patient are due to thromboembolism, pulmonary hypertension.
We describe a case of HCC that extended to the IVC and the RA complicated by pulmonary embolism. The main clinical manifestation of vena cava extension of the tumor is peripheral edema as in our case. Possible cardiopulmonary complications include heart failure, tricuspid insufficiency, ventricular out-flow tract obstruction, sudden cardiac death, pulmonary metastasis, secondary Budd–Chiari syndrome, pulmonary embolism and tricuspid stenosis, in particular our patient presented these two last complications .
This case is a timely reminder of the role that rapid evaluation by lung-cardiac-inferior vena cava integrated ultrasound retains in the management of the dyspneic patients, particularly when cases are complicated . Routine POCUS in patients with acute dyspnea allows timely assessment of heart size and function, and also rapid evaluation of lung and IVC that together with clinical assessment are able to identify the correct diagnosis within the different clinical pictures of dyspneic patients . Furthermore it allows to recognize a wide spectrum of conditions that are notably difficult to identify in the first assessment of the patients without more costly imaging modalities .
The integrated ultrasound examination of lung-heart-inferior vena cava is an extension of the clinical examination. In particular, Point-of-care ultrasound done in emergency department can be of a great help in rapid identification of correct diagnosis in patients with heart failure even in presence of rare conditions (such as cardiac masses) that require usually more advance imaging modalities.
AST: Aspartate aminotransferase
ED: Emergency Department
GFR: Glomerular Filtration Rate
HCC: Hepatocellular Carcinoma
HF: Heart Failure
HR: Heart rate
IVC: Inferior vena cava
LAFB: Left anterior fascicular block
LV: Left ventricle
NT-pro-BNP: N-Terminal pro-Brain Natriuretic peptide
POCUS: Point-of-care ultrasound
RA: Right atrium
RBB: Right bundle branch block
RV: Right ventricle
TS: Tricuspid stenosis
- Reynen K, Köckeritz U, Strasser RH. Metastases to the heart. Ann Oncol. 2004 Mar;15(3):375-81.
- Yu K, Liu Y, Wang H, Hu S, Long C. Epidemiological and pathological characteristics of cardiac tumors: a clinical study of 242 cases. Interact Cardiovasc Thorac Surg. 2007 Oct;6(5):636-9.
- Vallakati A, Chandra PA, Frankel R, Shani J. Intra-atrial tumor thrombi secondary to hepatocellular carcinoma responding to chemotherapy. N Am J Med Sci. 2011 Sep;3(9):435-7. .
- Leja MJ, Shah DJ, Reardon MJ. Primary cardiac tumors. Tex Heart Inst J. 2011;38(3):261-2.
- Ananthasubramaniam K, Farha A. Primary right atrial angiosarcoma mimicking acute pericarditis, pulmonary embolism, and tricuspid stenosis. Heart. 1999 May;81(5):556-8.
- Popat J, Rivero A, Pratap P, Guglin M. What is causing extremely elevated amino terminal brain natriuretic peptide in cancer patients? Congest Heart Fail. 2013 May-Jun;19(3):143-8. .
- Yap LB, Mukerjee D, Timms PM, Ashrafian H, Coghlan JG. Natriuretic peptides, respiratory disease, and the right heart. Chest. 2004 Oct;126(4):1330-6.
- Sung AD, Cheng S, Moslehi J, Scully EP, Prior JM, Loscalzo J. Hepatocellular carcinoma with intracavitary cardiac involvement: a case report and review of the literature. Am J Cardiol. 2008 Sep 1;102(5):643-5. .
- Sforza A, Mancusi C, Carlino MV, Buonauro A, Barozzi M, Romano G, Serra S, de Simone G. Diagnostic performance of multi-organ ultrasound with pocket-sized device in the management of acute dyspnea. Cardiovasc Ultrasound. 2017 Jun 19;15(1):16.
- Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, Stefanone VT, Savinelli C, Coppa A, Bigiarini S, Caldi F, Tassinari I, Conti A, Grifoni S, Pini R. Point-of-care ultrasonography for evaluation of acute dyspnea in the emergency department. Chest. 2017 Feb 14. .
- Motazedian P, Le May MR, Glover C, Hibbert B. A Woman in Her 80s With Anterior ST-Elevation Myocardial Infarction and Shock. Chest. 2017 Jan;151(1):e5-e8.