Critical Care: Student/Resident Case Report Poster - Critical Care I |

A Rare Case of Cardiogenic Shock Due to Epithelioid Angiosarcoma of the Heart FREE TO VIEW

Yi Chun Yeh, MD; Raymundo Quintana-Quezada, MD; Uday Gajjandra Sandhu, MD; Bader Aldeen Alhafez, MD; Rosa Estrada-Y-Martin, MD
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University of Texas, Health Science Center/McGovern School of Medicine at Houston, Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):382A. doi:10.1016/j.chest.2016.08.395
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Malignancy is the most common etiology behind hemorrhagic pericardial effusion; however, these are often metastatic or local spread disease. We describe a rare case of primary cardiac epithelioid angiosarcoma, with initial presentation as cardiac tamponade leading to multi-organ failure.

CASE PRESENTATION: A 75-year-old woman presented to our hospital with nausea and vomiting for 3 hours. In the EC, she was found to be hypothermic, hypotensive, and hypoxic. She was tachycardic and tachypneic with prominent jugular venous distension but no peripheral edema. Initial blood work was significant for pH of 7.16, lactic acid of 15.5mg/dL, elevated troponin, creatinine, and transaminases. She required high dose vasopressors and mechanical ventilation. Bedside US revealed large pericardial effusion with diastolic collapse of the right atrium (RA) and the right ventricle. An emergent pericardial window was performed and 450ccs of hemorrhagic pericardial fluid was drained. Pericardial biopsy, cytology, and cultures were unremarkable. Three months after discharge, she returned with similar presentation. Repeat TTE showed a fixed, 7 cm echogenic mass posterior to the RA that extended into the pericardial space and a large effusion. Cardiac MRI showed an asymmetric mass that had T1 and T2 heterogeneous signal intensity and contained a focal papillary projection into the RA and abut the lateral tricuspid leaflet with focal area hyperdensity suggesting a blood clot. She underwent repeat pericardiotomy via median sternostomy for both evacuation of the hematoma and evaluation of the mass; however due to the location of the lesion and the thrombus, only biopsy was performed. Pathology revealed epithelioid angiosarcoma; CD31, CD34, vimentin, and WT-1 positive. Her course of hospitalization was complicated by arrhythmia but all of which self-resolved within 2 weeks post-op. Staging CT ruled out metastasis or other possible primary malignancy. She refused further interventions and was discharged to follow in oncology clinic.

DISCUSSION: Angiosarcoma of epithelioid variant has been described in various tissues but only three other cases reported heart as primary origin. The initial manifestations of primary cardiac tumors are often non-specific, ranging from nausea to cardiogenic shock, therefore diagnosis is extremely challenging. In our patient, multiple imaging modalities and histologic analysis were required to unveil the culprit.

CONCLUSIONS: Due to its prognostic and therapeutic implications, it is imperative to consider cardiac malignancies in patients presenting with cardiac tamponade or hemorrhagic pericardial effusions without a clear etiology.

Reference #1: Matzke LA et al. A rare cardiac neoplasm: case report of cardiac epithelioid angiosarcoma. Cardiovasc Pathol. 2011;20:197-201

DISCLOSURE: The following authors have nothing to disclose: Yi Chun Yeh, Raymundo Quintana-Quezada, Uday Gajjandra Sandhu, Bader Aldeen Alhafez, Rosa Estrada-Y-Martin

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