Case Report

Patient with Right Cardiac Failure due to

Right Atrium and Inferior Vena Cava Thrombus
Tumor Related to Hepatocellular Carcinoma

Mukhammad Burhanuddin

Department of Internal Medicine

Dr. Soetomo Hospital – Faculty of Medicine
Universitas Airlangga Surabaya
July 23, 2020
INTRODUCTION

• Liver cancer  6th most common cancer,

4th cause of cancer mortality.
• Hepatocellular carcinoma (HCC) = 90% of
primary liver cancer.
• 90% of HCC aetiology = chronic viral hepatitis
(B and C), alcohol intake and aflatoxin.
• 1/3 cirrhotic patients will develop HCC

(Brat et al, 2018 ; EASL, 2018).

• HCC = aggressive tumor  tendency to
grow into the blood vessels 
tumor thrombus (TT) formation.

• In 0.67–4.1% of HCC : Tumor thrombus

invades the inferior vena cava (IVC) and
right atrium (RA)  lead to cardiac failure
or pulmonary embolization  prognosis
is very poor.

(Li et al, 2017 ; Numan et al, 2019).

 CASE
Identities Chief Complaint
• Mr. EB • Dyspnea and
• 33 yo shortness of breath 4
• Asem Bagus, months before
Surabaya admission
• Javanese, Moslem • Swelling of his
abdomen and both his
lower ekstremity
• Adimitted on: July 10, • Decrease of appetite
2018
• Med.Rec.Num:
12683941
HISTORY – Past Illness
• 4 month ago 
– He was admitted to William Booth Hospital for 2
weeks due to lost of consciousness
– He was diagnosed with hepatic cirrhosis due to
hepatitis B infection, right-sided heart failure, and
right-sided pleural effusion
– Tx: Lamivudin 1x100 mg, bisoprolol 1x5 mg and
furosemide 1x40mg.

HISTORY – Family Illness

• No history of the same disorders
 PHYSICAL EXAMINATION
July 10, 2018
Head/Neck:
• General Jaundice(+),
Condition: Weak Dyspneu(+), Elevated
JVP (10 mm H2O)
• Nutrition Status: Heart: cardiomegaly,
Normal gallop sound (+),
Lung: vesikuler
• Vital Signs: decreased,
• GCS 4-5-6 Rhonchi (+)
• BP 110/65 Abd: distended,
• Pulse 104 shifting dullness (+),
• RR 28 liver&spleen cannot
• Temp 38oC be evaluated
• SaO2 99% Extremities: warm (+),
(mask 6 lpm) dry (+), red (+), CRT
<2’, pitting edema (+)
in lower ekstremity
 LABORATORY FINDINGS
Clinical
Hematology Urinalysis BGA
Chemistry
Hb 11.4 g/dL RBG 91 mg/dL Glucose negative pH 7.52
HCT 43.3% AST 250 U/L Ketone negative pCO2 50 mmHg
WBC 10.8x103/μL ALT 89 U/L Blood [+3] pO2 139 mmHg
Neutrophils 73.5% Albumin 2.14 g/dL Protein [+1] HCO3 40 mmol/L
PLT 200x103/μL BUN 9 mg/dL BE 17.9 mmol/L
PPT 14.4 s Creat. 0.63 mg/dL SO2 99%
APTT 31.9 s Na 132 mEq/L
K 3.7 mEq/L
Cl 88 mEq/L
T. Bil 2.83 mg/dL
D. Bil 1.96 mg/dL
Other:
HbsAg (rapid test)  reactive
 CXR ECG

sinus tachycardia 110x/minute,

Pulmonary inflammation frontal plane: Right Axis Deviation,
Pleural Effusion D horizontal plane: clockwise rotation
Cardiomegaly right atrial abnormalities
 Transthoracic echocardiography:
 mass at right
atrium with the
largest
diameter 4,2
cm x 3,8 cm
 Mobile
 continuing to
the RV in
conjunction
with the
systolic and
diastolic
phase.
 CONSULTATION
• Department of Internal Medicine
– SH Child C (Hep B related)
– Hipoalbumin 2,1

• Department of Cardio-Thoracic-Vascular Surgery:

– ready for RA myxoma excision with optimal preparation of
patient’s general condition and vital sign, and
– management of liver cirrhosis is according to the Gastro-
Entero-Hepatology Department.

• Department of Pulmonology:
− suspected for acute tracheobronchitis and
− suspected organized right-sided pleural effusion.
 INITIAL ASSESMENT
• Diagnosis:
– Acute Right Heart Failure + suspected for RA myxoma dd
thrombus + Liver Cirrhosis Child C (Hepatitis B related) +
right-sided pleural effusion + suspected for
tracheobronchitis.

• Planning:
– Laboratory examination 
• Tumor markers (AFP, CEA, Ca 19-9)
• Anti HCV
• Serial measurement of AST, ALT, direct and total bilirubin
(every 3 days), albumin serum post transfusion
– Radiology examination 
• Transthoracic echocardiography (in the ward)
• Thoracoabdominal CT with contrast
• Thorax marker ultrasound
THERAPY
• Diet for liver disease tipe H2
– 40 kcal/kgBW/day
– protein 1,2-1,5 grams/kgBW
• NaCl 0,9% infusion 500 mL per 24 hours (fluid input =
fluid output)
• Albumin 20% 100 cc transfusion in 4 hours per 24 hours
• Ceftriaxone injection 1 gram twice daily intravenously
• Levofloxacin infusion 750 mg once daily intravenously
• Furosemide injection 40 mg thrice daily intravenously
• Spironolactone 25 mg once daily per os
• N-acetylcysteine 200 mg thrice daily per os
CLINICAL PROGRESS
3rd-8th day of admission

S: shortness of breath (+)

O: looked ill & weak, GCS 456, BP 120/60 mmHg, HR 132x/m,
RR 24 x/m, T 38,5oCelsius, SaO2 99% (nasal canule 4 lpm).
Repeat transthoracic echocardiography: 4x3,6 cm immobile
mass at the RA protruding to the RV, following the
dynamics of diastolic and systolic phases.
A: Right Heart Failure + tumor thrombus RA et IVC +
Hepatocellular carcinoma BCLC D + Hepatitis B + right-sided
pleural effusion + Tracheobronchitis
PDx: tumor markers (awaiting results)
PTx: risk and benefit assessment of RA and IVC thrombus
evacuation, considering palliative approach
Transthoracic echocardiography (2)

• 4x3,6 cm
immobile
mass at the
RA protruding
to the RV,
following the
dynamics of
diastolic and
systolic
phases.
 Thoraco
abdominal
CT

• thrombus at inferior vena cava measuring ± 1,2 cm in length and at right atrium measuring ±
1,9x2,7x1,8 cm in volume, suspected for metastatic thrombus tumor,
• Bilateral pleural effusion, multiple nodules in both pulmonary lobes and right and left hepatic
lobes suspected for metastatic process,
• hepatomegaly ± 15,88 cm
CLINICAL PROGRESS
13th day of admission

S: Shortness of breath (+) particularly when lying on his right side

O: Ascites was slightly improving, and pedal edema was also improving.
Laboratory: AFP 93581,6 (normal < 15), CEA 1,09 (normal < 5), Ca125
465,6 (normal < 35), Ca 19-9 115,69 (normal < 37). Anteroposterior
Chest X-Ray: Reticulonodular pattern at both lungs, differentials: 1)
metastatic process, 2) pulmonary inflammation, bilateral pleural effusion
(more prominent at the right side).
A: Right Heart Failure + tumor thrombus RA et IVC + Hepatocellular
carcinoma BCLC D (suspected pulmonary metastases) + Hepatitis B +
right-sided pleural effusion
PTx: Department of Cardio-Thoracic-Vascular Surgery: decided to abort
the surgery and proceed to palliative approach, Cardiology Department: no
specific treatment (treat the underlying malignancy disease), palliative
approach to the BCLC D hepatocellular carcinoma, and the patient was
given hepatitis B antiviral (tenofovir)
CLINICAL PROGRESS
17th day of admission

S: Shortness of breath worsen (+++)

O: weak, GCS 345 (delirium), BP 110/60 mmHg, HR 80 x/m, RR 40 x/m,
temperature 36,8oCelsius, SaO2 89% (nasal cannula 4 lpm). Laboratory:
blood gas (with non-rebreathing mask 10 lpm ): pH 7,41, pCO2 25, pO2
156 BE -8,8 HCO3 15,8 SaO2 99%
A: Right Heart Failure + tumor thrombus RA et IVC + Hepatocellular
carcinoma BCLC D (suspected pulmonary metastases) + Hepatitis B +
right-sided pleural effusion
PTx: supportive

He was then apneic and cardiac arrest, 18 hours after the initial
desaturation. Resuscitation was performed for 20 minutes but ROSC was
not achieved, with both pupils totally dilated. The patient was declared
deceased. Causa mortis: suspected pulmonary emboly and cardiovascular
event.
DISCUSSION
 (PPHI, 2017)
The patient fullfilled the criteria for diagnosed as Hepatocellular
carcinoma (HCC)
HCC  Aggressive tumor
– may grow into the blood vessels resulting in tumor thrombus (TT) formation.

TT Classification:
– Type I inferior hepatic TT  involves IVC below the diaphragm
– Type II superior hepatic TT  involves IVC above the diaphragm
but outside RA
– Type III intracardiac TT  TT above the diaphragm that reaches the RA

(Wang, et al., 2013); (Lin, et al., 2007; Sakamoto, et al., 2018)

The patient was classified into type III or intracardiac TT

Common clinical presentations of IVC/RA TT :
– abdominal pain & distension
– mild fever
– lower extremity edema
– palpable mass
– acute/subacute Budd-Chiari Syndrome (in some cases)
– right heart failure
– dyspnea
– syncope
– pulmonary embolism
– sudden cardiac arrest
– systemic metastase
(Numan, et al., 2019)
 Child – Turcotte – Pugh Score

The patient was diagnosed Liver Cirrhosis Child C

(Hepatitis B related)
 (Spengler, 2014 ; EASL 2018)

The patient was diagnosed Liver Cirrhosis Child C

(Hepatitis B related)
 • Cirrhosis  hyperdynamic circulation with increased
cardiac output and decreased vascular resistance.

• The cirrhotic liver more susceptible to hypoxemia and

hypotension in the operating room.

• Patient with liver cirrhosis who undergone

cardiopulmonary bypass surgery : mortality rate in CTP
A (0 % and 3 %), which greatly increased in CTP B (42 %
and 50 %) and CTP C (100 %).

(Friedman, 2010).

The patient with CTP C is very high risk to undergo

cardiopulmonary bypass surgery.
 Algorithm for the preoperative assessment of patients with liver disease

(Kholili and Syalini, 2016).

The patient with CTP C is very high risk to undergo
cardiopulmonary bypass surgery.
• Tx HCC and TT extending into the RA is difficult and risky.
• The prognosis is dismal if only supportive care is provided
(median survival 5 months)
• Surgery Procedures;
–Type I: radical hepatectomy
–Type II: total hepatic vascular exclusion (THVE)
–Type III: extracorporeal circulation (ECC)
• Patients with decompensated liver cirrhosis, advanced stage
of the primary tumor, and distant metastases are not
considered surgical candidates.

(Chang, et al., 2004 ; Sakamoto & Nagano, 2018)

The patient was not considered surgical candidates

 • Increased risk of systemic metastasis, impending
death due to pulmonary embolism or sudden
cardiac arrest  prognosis dismal.
• Sudden death can occur due to right heart failure
or pulmonary embolization.

(Wang et al., 2013 ; Li et al, 2017)

• Department of Cardio-Thoracic-Vascular Surgery was aborting the

surgery and giving a palliative approach.
• Cardiology Department decided to give no specific treatment but
treat the underlying malignancy disease and plan for palliative
approach to the BCLC D hepatocellular carcinoma.
• Internal Medicine Department was planning to start hepatitis B
antiviral (tenofovir) accompanied with supportive and symptomatic
therapy.
BCLC Staging system and Therapeutic Strategy

Llovet, 2018 ; EASL 2018

Natural History and impact of therapies in HCC

• Natural history, impact of therapies, and unmet needs in HCC.

Llovet, 2018
CONCLUSION
It was reported a 33 years old male patient
with acute right heart failure due to right atrium and
inferior vena cava thrombus tumor related to
hepatocellular carcinoma BCLC D + liver cirrhosis
child c (hepatitis b related) + right-sided pleural
effusion.
A conference among cardio-thoracic-vascular
surgery, cardiology and internal medicine
departments decided to abort the surgery and
proceed to palliative approach based on the
management of hepatocellular carcinoma BCLC D.
At the 17th day of admission, the patient was
passed away. The cause of the death was suspected
pulmonary emboly and cardiovascular event.
However, expansion of the thrombus to IVC and right
atrium is rare and indicates poor prognosis.
THANK YOU