Case Report

Right ventricular endocardial tumor mimicking acute massive pulmonary embolism

acute massive pulmonary embolism is one of the most challenging conditions in emergency medicine in which missed or delayed diagnosis can result in significant morbidity and mortality. The clinical presentation of dyspnea, hypotension, and cyanosis is indicative of life- threatening massive PE and requires Prompt diagnosis and immediate thrombolytic therapy or surgical embolectomy. A right ventricular tumor that bears the same presentation as acute massive PE is rare. We report herein a patient who presented with Classic symptoms and signs of acute massive PE and was subsequently found to be a case of right ventricular endocardial tumor. The possibility of a right ventricular tumor should be excluded before a diagnosis of massive PE is made because the management of a right ventricular tumor is quite different from that of massive PE.

Massive pulmonary embolism (PE) complicated by cardiogenic shock is a life-threatening medical emergency that has an exceptionally high mortality [1] and requires immediate aggressive management, including thrombolytic therapy or surgical embolectomy [2]. The clinical presen- tation of dyspnea, hypotension, and cyanosis is indicative of life-threatening massive PE, and differential diagnoses include pneumonia, acute right-sided heart failure secondary to Right ventricular infarction, cor pulmonale with acute decompensation, and tamponade. But a right ventricular neoplasm that has the same presentation as acute massive PE is rare [3-5]. Early recognition and surgical intervention is crucial for a favorable outcome or palliation [6,7]. We report herein a patient who presented with classic signs and symptoms of acute massive PE but was subsequently found to have a right ventricular endocardial tumor.

The patient was a 23-year-old man who consulted at the emergency department (ED) for progressive dyspnea. He had a history of a mature mediastinal teratoma and underwent tumor resection, radiotherapy, and chemotherapy 4 years ago. The posttreatment course was uneventful. He had no dyspnea, chest pain, or other constitutional symptoms until 3 days before this admission.

The physical examination revealed clear consciousness. His blood pressure was 106/54 mm Hg, his respiratory rate was 28 breaths/min, and his heart rate was 123 beats/min. He had mouth-lip cyanosis, dry mucous membrane,

engorged jugular veins, and an operative scar at the left chest wall. The breath sounds were clear. The heart sounds were regular with no murmurs. There was hepatomegaly and tenderness in the right upper quadrant of the abdomen, but there was no Leg swelling or edema.

There was prominent thrombocytopenia (29000/lL) as

well as elevated serum levels of creatinine (2.08 mg/dL), aspartate aminotransferase (139 U/L), and alanine amino- transferase (134 U/L). Chest x-ray showed that the lung parenchyma was clear except for a small (29 x 25 mm) well-demarcated nodule at the right lower lobe and cardiomegaly (Fig. 1). A 12-lead electrocardiogram showed junctional tachycardia, Deep S wave in lead I, q- wave and T-wave inversion in lead III (S₁Q₃T₃ pattern), and incomplete right bundle-branch block suggestive of right ventricular strain (Fig. 2). An initial working diagnosis of acute massive PE was made.

Fig. 1 Chest x-ray showed cardiomegaly and a well-demarcated right lower lobe nodule measuring 29 x 25 mm. There was an elevation of the left hemidiaphragm and postoperative changes of the upper mediastinum. The lung parenchyma was clear.

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Fig. 2 The 12-lead ECG demonstrated junctional tachycardia, deep S wave in lead I, q-wave and T-wave inversion in lead III (S₁Q₃T₃ pattern), and incomplete right bundle-branch block suggestive of right ventricular strain.

However, emergent contrast-enhanced multidetector row computed tomography (CT) demonstrated an intraventricu- lar tumor occupying nearly the whole right ventricle and extending into the right atrium (Fig. 3). The hepatic veins and inferior vena cava were engorged, but there was no filling defect in the pulmonary trunk and its branches. Echocardiography showed a heterogeneous lob- ulated mass in the right ventricle that extended into the right atrium and compromised both the right ventricular inflow and outflow.

The patient’s condition deteriorated drastically. Altered consciousness and respiratory failure developed half an hour after his arrival at the ED. Profound metabolic acidosis, hypotension, and hypoxemia ensued despite mechanical ventilatory support, intravenous fluid challenge, sodium bicarbonate replacement, and high-dose vasopres- sor and inotropic supplementation. A cardiovascular surgeon was informed for emergency operation, but the patient’s condition further deteriorated. He was in a state of persistent refractory shock and died 10 hours after the arrival at the ED.

Although primary cardiac neoplasms are only scarcely reported, the occurrence of cardiac metastases in general is not a rare event [8]. However, cardiac metastases tend to be clinically silent and are diagnosed mostly during the autopsy studies [9]. In a large series reported by Bussani et al [10], the incidence of metastatic cardiac involvement was 9.1%. About half of all cardiac metastases involve the pericardium (49.4%), the epicardium (24.4%), the myocardium (22.6%),

and the endocardium (3.6%). The rarity of endocardial metastases has been attributed to the strong kneading action of the heart, the metabolic peculiarities of the myocardium,

Fig. 3 Enhanced multidetector row CT showed a dilated right ventricle filled with a large soft-tissue mass (T) protruding into the right atrium (RA). The Left ventricle and left atrium were compressed.

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the rapidity of Coronary blood flow, and the lymphatic connections that drain afferently from the heart [11].

Depending on the site and extent of the cardiac involvement, as well as the patient’s underlying cardiopul- monary reserve, the presenting signs and symptoms vary widely from fatigue, exertional dyspnea, orthopnea, cough, hemoptysis, syncope, chest pain, peripheral edema, hepa- tomegaly, cyanosis, and arrhythmias to frank cardiogenic shock [12]. This patient had a large right ventricular tumor occupying the whole ventricular cavity, which caused obstruction of the inflow and outflow of the right ventricle as well as reduced diastolic left ventricular distensibility due to interventricular septal displacement. This resulted in chest x-ray and ECG findings, as well as clinical presentations, of low cardiac output due to acute right ventricular failure; all are the same presentations of acute massive PE.

Acute massive PE is one of the most challenging conditions in emergency medicine in which missed or delayed diagnosis can result in significant morbidity and mortality. The possibility of a right ventricular tumor should be excluded before a diagnosis of massive PE is made because the management of a right ventricular tumor is very different from that of massive PE. An emergent contrast-enhanced CT can help establish the diagnosis early and should be immediately performed at the ED.

Chih-Hsin Lee MD Mei-Chen Yang MD Shih-Tsung Cheng MD Heng-Chia Chang MD

Department of Internal Medicine Buddhist Tzu Chi General Hospital Taipei Branch, Taipei, Taiwan

E-mail address: [email protected]

Kun Eng Lim MD Department of Clinical Radiology Buddhist Tzu Chi General Hospital

Taipei Branch, Xindian 231 Taipei, Taiwan

doi:10.1016/j.ajem.2007.02.020

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