Case Reports

Cardiac failure due to left atrial angiosarcoma


 

References

Abstract

Primary heart sarcomas are rare and represent 20% of all primary cardiac tumors. Symptoms depend on which chambers and cardiac structures are involved. Angiosarcoma is one of the most common and the most aggressive types of primary heart sarcomas. Typically, these tumors are found in the right atrium, however, cardiac angiosarcomas may involve any part of the heart. Most of these tumors are diagnosed in advanced stages and the patient prognosis is poor. Most tumors are diagnosed using echocardiography. Computed tomography (CT) and magnetic resonance imaging (MRI) provide useful information on tumor size and location for planning surgery, which is the only treatment shown to increase survival. We present the case of a 69-year-old woman who presented to the emergency department with hypotension, dyspnea and progressive shortness of breath. After adequate resuscitation, a cardiac mass was identified and surgery was successfully performed. Pathology confirmed a grade 2 primary heart angiosarcoma. Following surgery, the patient was admitted to the intensive care unit and later died secondary to multi-organ system failure.

Introduction

Primary heart angiosarcoma is an aggressive and usually fatal cardiac neoplasm (1). Angiosarcomas can originate at any location in the heart (2, 3), but these tumors typically reside in the right atrium and frequently cause nonspecific symptoms such as dyspnea, cough, heart failure, and arrhythmias. (2) Surgery followed by chemotherapy is the typical approach to these tumors. (4)

We present the case of a 69-year-old woman who presented to the emergency department with hypotension and severe dyspnea.

Case Report

The patient was a 69-year-old woman with a medical history of diabetes. A week before seeking care in the emergency department, she experienced a general feeling of unwellness, dyspnea, and mild respiratory distress. She reported these symptoms had become more and more severe in the last 24 hours and were accompanied by acute chest pain and progressive shortness of breath.

On clinical examination, the patient was hypotensive, had tachypnea and tachycardia, and was hypoxic. Cardiac auscultation detected a systolic murmur in the apex, and auscultation of the lungs revealed crackles and rales, especially at the bases of the lungs. The remainder of her clinical examination was unremarkable. She had sinus tachycardia on an electrocardiogram. A chest X-ray showed a left atrial enlargement along with some patchy opacities in the middle and lower zones of the lungs, along with Kerley B lines suggestive of pulmonary edema.

With these findings, and after adequate resuscitation, a contrast-enhanced computed tomography (CT) scan detected a filling defect in the left atrium suggestive of a large intra-cardiac mass with a thick and hyper-enhanced interatrial septum. Bilateral pleural effusions also were evident, (Figure 1A) hence an echocardiogram was requested and it confirmed the presence of a 30 x 29 x 40 mm lobulated highly mobile mass in the left atrium.

Figure 1A: Contrast-enhanced chest CT, a filling defect in the left atrium, with a thick and hyper-enhanced interatrial septum and bilateral pleural effusions are seen.

The mass had a heterogeneous echogenicity along with some hypoechogenic areas. The tumor was attached to the surface of the anterior leaflet of the mitral valve and had a broad base that extended towards the interatrial septum. In the diastolic phase, the lesion insinuated towards the ventricle without exceeding the limits of the leaflets, causing severe valve dysfunction, (Figure 2A).

Figure 2A: Echocardiography revealing the cardiac mass within the left atrium.

Diminished left ventricular ejection fraction was noted as well.

After a cardiothoracic consultation, cardiac magnetic resonance imaging (MRI) was performed. The findings showed the presence of a 58 x 45 x 6 mm well-circumscribed hyperemic mass on the anterior leaflet of the mitral valve and a second 10 x 10 x 6 mm smaller mass firmly adhered to the posterior leaflet of the mitral valve.

Figure 3A: Cardiac MRI, a well-circumscribed hyperemic mass, on the anterior leaflet of the mitral valve is seen.

As contrast passed through the coronary arteries, the contrast filled the mass confirming its vascular nature (Figure 3A).

The patient, who was hypotensive and hypoxic, was admitted to the hospital for surgical treatment.

Following sternotomy and cardiopulmonary bypass, a right atriotomy was performed using a trans-septal approach. The large left atrial mass was firmly adhered to the endocardium at the level of the anterior leaflet of the mitral valve and the interatrial septum. The mass had a grey and whitish appearance with some bluish necrotic patches, (Figure 1B, 2B, 3B).

Figure 1B: Left atrium mass firmly adhered to the endocardium at the level of the anterior leaflet of the mitral valve and the interatrial septum

A second 14x10x6 mm mass and a small 1x1x5 mm mass firmly adhered to the posterior leaflet of the mitral valve.

Figure 2B: Resection of the left atrium mass after cardiopulmonary bypass

Based on these findings, the cardiac masses were completely resected and bovine pericardium was used to repair the septal defect and the mitral valve leaflets.

Figure 3B: Complete resection of the left atrium mass

The remainder of the procedure continued without any complications. Pathology reported a tumor that consisted of spindle-shaped tumor cells, with significant pleomorphism and numerous irregular vascular channels. Cells were strongly positive for CD34 and weakly positive for FLI-1. A grade 2 primary heart angiosarcoma was the final diagnosis. (Figure 1C, 2C, and Supplementary Video )

The patient had a complicated postoperative course in the Intensive Care Unit (ICU) and needed inotropic support and vasoactive agents. A postop echocardiogram indicated appropriate left ventricle systolic function, nonetheless, the patient persisted in a hypotensive status that caused refractory shock and ultimately provoked severe organ dysfunction that led to the patient’s death.

Discussion

Primary heart sarcomas are extremely rare malignant neoplasms derived from mesenchymal cells, (1) with an incidence ranging from 0.001% to 0.28% at autopsy.

Figure 1C: Hematoxylin-Eosin staining, lesion constituted by spindle-shaped tumor cells, with important pleomorphism. (400x magnification)

(2) Primary heart sarcomas represent 10% to 20% of all primary heart tumors, (3) and are thought to arise from a pluripotent mesenchymal cell with k-ras and p53 mutations, however, the molecular histogenesis pathways are still poorly understood. (1) Primary heart sarcomas are classified according to their cell pattern, undifferentiated sarcomas and angiosarcomas are the two most common types, accounting for up to 66% of all primary heart sarcomas.

Figure 2C: Immunohistochemically stain for CD-34 in endothelial cells (400x amplification)

(1, 3) Primary heart sarcomas may originate from any part of the heart, without any gender or age predominance. (1) They can also arise from surrounding cardiac structures and are capable of mimicking almost any cardiovascular disorder. (2)

Cardiac angiosarcomas (CA) account for one-third of all primary heart sarcomas (4) and usually develop as gray-brown masses with hemorrhagic patches in the right atrium of male patients. The tumors are filled with vascular channels and their cells are positive for CD34 and factor VIII. (5) Left-sided cardiac angiosarcoma can cause heart failure early in the disease process, but the tumors tend to be more circumscribed, less infiltrative, and associated with better overall survival. (6, 7) Most patients are asymptomatic early in their disease, (2) making the diagnosis even more difficult and worsening its already poor prognosis. (1) The preference of cardiac angiosarcomas for the right heart often leads to a presentation with right-sided congestive heart failure. (2) At later stages, symptoms depend on the structures compromised and range from mild dyspnea on exertion to cardiogenic shock. (8) Cardiac angiosarcomas tend to have a notable intracavitary element, and in some cases may intermittently compromise a cardiac valve, thereby simulating a stenosis or regurgitation. (2, 7)

Our patient presented with acute cardiac failure, pulmonary edema and severe valve dysfunction due to a mass in the left atrium. The tumor had a vascular supply and showed positivity for CD34.

Most patients with cardiac angiosarcoma have metastases, typically to the lung, at diagnosis. (1) Several decades ago, cardiac angiosarcoma was mainly diagnosed postmortem. (1) Now, it can be suspected when cardiomegaly or pleural effusions are seen on chest x-rays (8). Echocardiography is the most useful diagnostic tool, (2) however, CT and MRI can provide useful information on tumor size, invasion and localization. (2, 9) This imaging combination generally provides an excellent anatomic description for preoperative planning. (1, 9)

In our patient, progressive dyspnea was the main symptom and after a prompt evaluation an intracardiac mass was identified as the cause of severe cardiac dysfunction. Because of this finding and the clinical condition of the patient, surgery was planned.

Complete resection of the tumor is the treatment of choice, and is the only therapy currently seen to influence survival. (8) But because of the highly aggressive behavior and a high incidence of systemic metastases with cardiac angiosarcomas, a complete surgical resection is often hampered. (1) Cardiac angiosarcoma carries a grim prognosis as these tumors are universally fatal with a mean survival time of several months after initial presentation even after successful surgery. (2) Chemotherapy is recommended after surgery, even when clear surgical margins are obtained because of the high probability of missed microscopic disease. (1, 2)

High clinical suspicion together with an appropriate history, a thorough physical examination, and precise complementary tests are vital for timely diagnosis and proper treatment.

Authors and Affiliations
Santiago A. Endara : Department of General Surgery, Division of Cardiothoracic Surgery, Hospital Metropolitano, Quito, Ecuador, MD
Gerardo A. Dávalos : Department of General Surgery, Division of Cardiothoracic Surgery, Hospital Metropolitano, Quito, Ecuador, MD
Patricia M. Pontón : Hospital Metropolitano, Quito, Ecuador. Department of Internal Medicine Division of Pathology, MD
Gabriel A. Molina : Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador. PGY4 General Surgery Resident, MD
Daniel L. Mogrovejo : Pontificia Universidad Católica del Ecuador (PUCE), Quito, Ecuador. PGY1 General Surgery Resident, MD
Corresponding Author Info:
Santiago A. Endara, Hospital Metropolitano, Av. Mariana de Jesus Oe 7/47 y Conclina, Edificio Diagnostico 2000 tercer piso 3/3, Quito, Ecuador, + 593 9 98416157
Email: drsantiagoendara@gmail.com

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