A 71 year old patient presented with a non-ST segment elevation acute myocardial infarction. The echocardiogram showed several masses attached to the interatrial septum. Several days after admission the patient died. A postmortem examination found a large hepatocarcinoma with intravascular and intracardiac metastases and several myocardial infarctions of different ages. The infarctions had been caused by coronary paradoxical embolisms through a patent foramen ovale and contained neoplastic cells from the liver carcinoma, which had not been diagnosed. The cause of death was a massive pulmonary embolism.A 71 year old man was admitted to the emergency department with typical oppressive chest pain accompanied by profuse sweating and mild dyspnoea lasting for three hours at the time of admission. The patient had a previous diagnosis of chronic C type hepatitis, porphyria, and mild chronic obstructive lung disease. The ECG showed block of the anterior division of the left bundle branch and 0.5 mV ST segment elevation in the right precordial leads. The patient was admitted to the coronary care unit and treated with nitrates, aspirin, diltiazem, and enoxaparin, becoming asymptomatic. The laboratory tests showed a rise and fall of the cardiac markers with a peak creatine kinase MB concentration of 40 ng/ml.On the third day a transthoracic echocardiogram showed a large mass in the right atrium arising from the inferior vena cava that was partially occupied. No abnormalities in global or segmental contractility in the left or the right ventricles were found. Transoesophageal echocardiography showed a large 6 6 3 cm mass placed against the interatrial septum ( fig 1A). The Doppler study showed a patent foramen ovale. Laboratory analyses showed a major increase of biochemical tumour markers, particularly a fetoprotein (more than 2500 ng/ml).The day after the transoesophageal echocardiogram was recorded, the patient presented with a sudden pleuritic chest pain, with severe dyspnoea and refractory hypoxaemia and cyanosis. Pulmonary arteriography was urgently performed, showing obstruction of the main right and left pulmonary arteries. Intra-arterial thrombolysis with urokinase was administered with no clinical or haemodynamic improvement. The patient died four hours later. The pathological findings showed several yellowish 2 cm diameter nodules in the liver. One of the masses had invaded the suprahepatic veins and the inferior vena cava ( fig 1C). Several masses were attached to the inferior vena cava and right atrial wall (fig 1B), as well as to a dilated right ventricle, main pulmonary arteries, and their distal branches. A 7-8 mm diameter patent foramen ovale was also found. Histological analysis of the hepatic masses showed neoplastic cells with an eosinophilic cytoplasm and areas of focal necrosis. The same type of neoplastic cells were found in intravascular and intracardiac masses. The epicardial coronary arteries had no signs of atherosclerotic obstructions but had several microscopic embolisms in the distal branches o...
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