Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

Abstract

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...

Acute myocardial infarction due to malignant neoplastic coronary embolus

“…To our knowledge, only 16 cases of malignant coronary emboli have been reported [7][8][9][10]. Lung carcinoma was the most common source and accounted for 11 of the 17 cases including our case.…”

Serpentine thrombus in the heart: a rare case of trapped thrombus in patent foramen ovale

“…It has been proposed that increased risk for paradoxical embolisation may be associated with the PFO size and the presence of atrial septal aneurysm, prominent Eustachian valve, Chiari network and hypercoagulability 13. Apart from Valsalva manoeuvre, PFO-related events may be provoked by other situations enhancing shunting by increase in right atrial pressure, including mechanical ventilation,14 diving,15 pulmonary embolisation16 or a right-sided cardiac tumour 17. It is implied in the literature that <1% of myocardial infarctions are caused by paradoxical embolism via an interatrial communication 18…”

Acute myocardial infarction caused by coronary tumor thromboembolism: a rare primary manifestation of malignant tumor disease

“…In addition, several case reports hint on the possibility of hematological tumor spread of solid malignant tumors into the coronary arteries with subsequent myocardial necrosis. This rare type of tumor-related death was observed in malignant hepatic tumors [3] and pancreatic carcinoma [4]. In patients with lung carcinoma, coronary tumor embolism is theoretically facilitated by the fact that direct embolism from pulmonary veins via the left heart in the coronary arteries is possible.…”