Article Details

Background
Cardiac tumors are relatively rare and can occasionally be detected on echocardiography but are often found incidentally on autopsy. Typically, primary cases are benign tumors such as myxomas, rhabdomyomas, or lipomas [1]. Most commonly, cardiac tumors are metastatic in nature. The most common primary sources include lung, mesothelioma, skin, and melanoma [2]. Rarely, hepatocellular carcinoma (HCC) can metastasize to the heart via direct tumor spread through the vena cava. We present an unusual case of HCC metastasized to the right atrium and subsequently caused embolic phenomenon and resulted in a submassive pulmonary embolism.

Case Description
We present the case of a 42-year-old male with a past medical history of hepatitis B and recently diagnosed HCC who initially presented for worsening abdominal distension. He was found to have a CT abdomen (Figure 1) with tumor extending in the inferior vena cava (IVC) into the right atrium. Magnetic resonance cholangiopancreatography (MRCP) (Figure 2) demonstrated worsening tumor burden. During the hospitalization, he developed sudden dyspnea and CTA thorax (Figure 3) demonstrated bilateral pulmonary embolism. Echocardiography (Figure 4) demonstrated a large mass compatible with known extensive tumor burden. The patient was started on heparin and was not a candidate for mechanical thrombectomy given extensive atrial and caval involvement. Unfortunately, the patient had progressive respiratory failure and died.

Conclusion
This case demonstrates a rare case of advanced HCC that had direct hematogenous spread through portal veins into IVC. In this patient's case, the burden was so significant that it extended into the right atrium.