Produção Nacional
Revisado por pares
Clinical Case Poster session 4
2017; Oxford University Press; Volume: 18; Issue: suppl_3 Linguagem: Inglês
10.1093/ehjci/jex289
ISSN2047-2412
AutoresA C Guta, A. Călin, Dan M. Dorobantu, Anca Burducea, Monica Roşca, Marian Croitoru, Carmen Ginghină, I Arkhipova, Н. Н. Илов, И. И. Чернов, О А Кондратьева, Tarasov, Josephine Obiageli Okafor, C Neagu, Diana Zamfir, Lucian Câlmâc, Cătălina Mihai, Maria Dorobanţu, J Rigueira, Andreia Magalhães, A Ferreira, I Aguiar-Ricardo, R Santos, Ramiro Gonçalves, Fausto J. Pinto, Ana G. Almeida, I Dentamaro, Girasoli, Ostuni, D'Agostino, Colonna, Isaac Tai, Lin I, C Lo, Yanming Huang, Kwang‐Huei Lin, Chiara Piazzai, Moggi Pignone, Gargani,
Tópico(s)Hematological disorders and diagnostics
ResumoIntroduction:The association between hepatocellular carcinoma and inferior vena cava (IVC) and right atrium (RA) thrombosis is rare, carries a poor prognosis and is usually a sign of advanced stage disease.Surgical treatment is an option, but satisfactory results are limited to early stage cancer.A multimodality imaging and multidisciplinary approach can help identify patients who might benefit from surgical treatment, rather than palliation.Case description: We present the case of a 69 year old male, with many cardiovascular risk factors, a history of coronary artery disease and intermittent claudication, referred to our clinic for treatment.He had been increasingly dyspneic in the three months preceding his hospitalization, with an episode of aggravated congestive heart failure, poorly responsive to maximal diuretic treatment one month prior.He also had a known hepatic nodule, which he neglected to follow-up.At admission he was in NYHA class III, had signs of right cardiac failure, otherwise an unremarkable examination.The brain-natriuretic peptide was increased (356 pg/ml), he had a mild hepatic cytolysis and simple chronic anemia with a modestly increased C reactive protein; the ECG showed atrial flutter.Due to the patient history, the symptoms were initially considered to be due to the untreated ischemic heart disease.The transthoracic echocardiography showed a large mass (59/38 mm) in the RA, with an irregular surface and hypermobile segments (A), mild tricuspid regurgitation and an estimated systolic pulmonary artery pressure of 48 mmHg, otherwise normal biventricular systolic function.The transesophageal echocardiography confirmed the presence of a large, multilobulated tumor in the RA, extended into the IVC (B).The thoraco-abdominal CT scan revealed a tumoral thrombosis extending from the hepatic veins through the IVC into the RA (C), multiple images suggestive of pulmonary thromboembolism, micronodules and adenopathies, several hepatic tumors (D) and a suprarenal mass.Since this is a patient with known arterial disease we performed an angiographic study which showed an 80% LAD stenosis, a diffusely infiltrated RCA with multiple significant stenosis and multiple femuro-tibial bilateral lesions.The case was presented in the multidisciplinary meeting where it was concluded that the extension of the neoplastic process, with multiple secondary lesions, was prohibitive for surgical treatment or chemotherapy, due to the severe coronary lesions.As such, palliation was recommended and the patient was started on oral anticoagulant, diuretics and ACE inhibitors, being referred to an oncological clinic for specialty care.Discussions: Extended central venous thrombosis secondary to a neoplastic process is often an incidental finding, many times with unspecific symptoms.Echocardiography remains the diagnostic option of choice, offering valuable data on size, extension and often can differentiate thrombi from other tumoral formations based on aspect, mobility and extension into the IVC/SVC.A complete, multimodality imaging study is mandatory, in order to diagnose the primary lesion, its extension and the presence of metastases, all important factors in deciding between aggressive therapy and palliation.Surgical care is usually associated with poor outcomes, dictated by the staging of the oncological disease, and less so by the nature and size of the thrombus.Conclusion: This case highlights the "cascade effect" going from a neglected hepatic nodular lesion to venous thromboses, eventually extended into the RA, causing heart failure, finally becoming apparent on echocardiography, with multimodality imaging, both cardiac and noncardiac, having an important role in the treatment decision.
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