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Right ventricular exclusion for hepatocellular carcinoma metastatic to the heart
© Liu et al; licensee BioMed Central Ltd. 2010
Received: 11 June 2010
Accepted: 30 October 2010
Published: 30 October 2010
We used for the first time a right ventricular exclusion procedure for the treatment of hepatocellular carcinoma metastatic to the right ventricle. Our case report shows that this surgical option can be effective as rescue therapy for right ventricular outflow tract obstruction secondary to myocardial metastasis in critically ill patients. Most notably, this technique can prevent inadvertent dislodgement of tumor cells.
Right ventricular outflow tract obstruction secondary to myocardial metastasis from hepatocellular carcinoma (HCC) represents a rare event and portends a poor prognosis [1–4]. The clinical picture is chiefly dominated by severe cardiorespiratory compromise that may lead to cardiac arrest. Surgical resection with therapeutic intent is not an option for the majority of patients with metastatic involvement of the heart. However, symptom relief after palliative surgery can improve quality of life. We hereby present a clinical case of intraventricular cardiac metastasis from HCC leading to right ventricular outflow tract obstruction. We used for the first time a right ventricular exclusion procedure as rescue therapy to relieve mechanical obstruction to blood flow and avoid life-threatening hemodynamic instability. In addition, this procedure can prevent inadvertent dislodgement of tumor cells.
A 46-year-old female patient complained of general weakness and increasing dyspnea for 1 month. She had been diagnosed 14 months earlier with a hepatocellular carcinoma for which she underwent extended right hepatectomy. After surgery, the patient was treated twice with transarterial chemoembolization for small recurrent HCC lesions. At the time of the second chemoembolization, computed tomography (CT) and magnetic resonance imaging (MRI) revealed a right ventricular mass resulting in right ventricular outflow tract obstruction. The patient was offered surgery but, being otherwise asymptomatic, she refused treatment at that time.
The patient experienced attacks of exertional dyspnea, and we performed transcatheter closure of the fenestration one month after TCPC. Arterial saturation improved significantly to 94% after fenestration closure, and exercise intolerance disappeared. Catheterization revealed a patent TCPC conduit. The patients refused to undergo the planned chemotherapy and radiotherapy for residual tumor in the right ventricle. She passed away four months after the surgery due to recurrence of HCC in liver.
Cases of HCC metastatic to the right ventricle are exceedingly rare and generally have a dismal prognosis [1–4]. There is only one report in the literature describing the use of cardiac surgery to remove a hepatocellular carcinoma that had metastasized to the right ventricle . Management of metastasis to the heart is palliative surgical excision and this was followed in our patient by debulking of the mass to relieve mechanical obstruction to blood flow and avoid life-threatening hemodynamic instability. Most notably, the total right ventricular exclusion procedure used in our patient provides a means for avoiding tumor fragmentation, dislodgement, or embolization.
To improve a poor prognosis of metastatic HCC, multimodal approaches combining chemotherapy, radiotherapy, and surgery may be useful. Interestingly, it has been recently suggested that the oral multikinase inhibitor, sorafenib, may produce a survival advantage in patients with advanced HCC . In conclusion, we used for the first time a right ventricular exclusion procedure for the treatment of HCC metastatic to the right ventricle. We believe that this surgical option can be effective as rescue therapy for right ventricular outflow tract obstruction secondary to myocardial metastasis in critically ill patients. Most notably, it can prevent inadvertent dislodgement of tumor cells.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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