Acute heart failure caused by a giant hepatocellular metastatic tumor of the right atrium

Hepatocellular metastatic carcinomas to the heart are uncommon malignant tumors that are usually located to the right atrium. Prompt diagnosis of their presence is of major clinical importance because although rare they can cause obstructive phenomena, heart failure and even sudden cardiac death [1-3]. Herein, we present a patient with a metastatic hepatocellular carcinoma located in the right atrium and invading the right ventricle, the pre op workout and the subsequent managementA 40 year old cirrhotic male was admitted to the cardiology emergency department due to sudden onsets of syncope. He also presented with exertional dyspnoea accompanied by continuous chest pain and cough. His medical history included hepatitis B marker positive. Clinical examination revealed cyanotic and swollen head and neck with distended jugular veins up to the angle of the mandible. His blood pressure was 98/62 mmHg and the oxygen saturation on room air was 90%. Cardiac rhythm was normal but the rate was increased. Electrocardiogram (ECG) showed sinus tachycardia (145 beats/min). Urgent cardiac ultrasound revealed a giant mass that partially occupied the right atrium. A subsequent urgent chest CT angiography presented a huge non-homogenous tumour occupying almost the entire right atrium and partially invading the right ventricle. The CT showed no liver tumour or other subdiaphragmatic tumour extension. (Figure 1)The patient underwent urgent surgical treatment due to worsening of his clinical condition. The findings of the CT guided our surgical strategy as follows: Initially femoro-femoral cannulation was installed in order to commence cardiopulmonary bypass (CPB). Thus the pericardial cavity could be approached with safety. After median sternotomy, the superior vena cava was also cannulated and transfixed and then antegrade cardioplegia was administered. The heart was cooled down to 30°C, the right atrium was incised and the large tumor was carefully and copiously dissected from the s