Cardiac tumours may be primary or secondary-metastatic (malignant).

Secondary cardiac tumours are much more common than primary cardiac tumours. Their frequency on large anatomical studies varies between 3.4% and 13.9%. Though cardiac metastases may originate from any malignant tumor, melanomas have the greatest propensity for cardiac involvement, and also carcinomas of the thorax, including breast, lung, and esophageal [12,13]. The routes of metastasis include direct invasion, hematogenous, lymphatic, or transvenous, especially through the inferior vena cava [9,10]. Cardiac involvement should be suspected or sought in any patient with a known malignancy who develops new cardiovascular signs or symptoms. Imaging methods - echocardiography, computed tomography (CT) and MRI, are essential in establishing the diagnosis and the invasion of the tumour in the cardiac cavity. The severe evolution of secondary cardiac tumors depends on the extension of the primary tumour, but also on the severity of the clinical cardiac manifestations. Generally, the treatment is surgical. A correct diagnosis is important in the clinical setting since cardiac metastases are able to induce sudden cardiac death1.

Primary hepatocellular carcinoma (HCC) is the sixth cause of cancer in the world and the second cause of cancer mortality worldwide, with more than 830,000 deaths recorded annually2.

We present a case of HCC growth into the vena cava inferior (VCI) and invasion into the right atrium (RA).

HCC- Hepatocellular carcinoma

VCI-vena cava inferior

RA-right atrium

TTE- transthoracicechocardiogram CT- computed tomography 

A 60-year-old man recently diagnosed with cirrhosis and HCC, secondary to hepatitis B, presented to the cardiology department for dyspnea and new onset bilateral lower extremity edema, rapidly progressing over 2 weeks. The patient is receiving treatment with Lamivudine 100mg.

The patient`s hemodynamic parameters showed regular sinus rhythm of 74 beats per minute, blood pressure of 130/80 mm Hg, heart sounds without murmurs and bilateral lower limb edema. There was no jugular venous distension, and his lungs were clear to auscultation.

Initial laboratory findings:

The ECG showed normalsinus rhythm.

The transthoracic echocardiogram (TTE)registered normal left ventricle systolicfunction without wall motion abnormality or significant valvular abnormality. Large echogenic 45/37mmmass, extending from the intrahepatic VCI to the RA, with no obstruction of the right ventricle. (Figure1,2)

                                                                                                           Figure 1: Huge right atrialmass

                                                                                      Figure 2: Mass extending from the intrahepatic VCI to the RA

CT scan of the chest and abdomen showed a large heterogeneous and roundedmass in the liver, with an axialdiameter of 13.54 cm (Figure3) and a coronary diameter of 13.84 cm (Figure 4); evidence of tumor extension to the adjacent VCI, reaching the RA (Figure5); thrombosis of the two common iliac arteries, the external and internal iliac veins on the right, as well as the proximal4.71 cm of the VCI (Figure 6); small amountof perihepatic ascites,and pulmonary nodules.

                                                                                                                                Figure 3.

                                                                                                                                  Figure 4.

                                                                                                                                 Figure 5.

                                                                                                                         Figure 6.

The CT scan was followed by a multidisciplinary discussion. Due to the advanced stage of the disease, it was concluded that the patient is indicated for palliative care. Tumor resection and liver transplantation are some of the treatment methods used in such cases, but their prognosis remains poor, with a median survival of only a few months [3,4,5]. Some of the limiting factors of surgical intervention include poor hepatic reserve, potential postoperative complications, and early recurrence [6,7].

Тransarterial chemoembolization, chemotherapy and radiotherapy are some of the potential treatment options, to relieve symptoms and improve quality of life [4,5,11]. The multimodality of cardiac imaging is important, because the diagnosis may be overlooked due to non-specific symptoms. Screening TTE is recommended in patients with HCC, even in the absence of cardiac manifestations. HCC with right atrial metastasis is associated with a high risk of cardiopulmonary complications, tricuspid stenosis or insufficiency, ventricular outflow obstruction, cardiac arrhythmias, pulmonary embolism, pulmonary metastases, heart failure or sudden death.

HCC with VCI and RA invasion has a poor prognosis and leads to an increased risk of cardiacdeath. It is rare and difficult to diagnose and treat8, because of the absenceof cardiac manifestations. Severe myocardial damagecaused by the tumor mass may occur, impairing cardiac function gradually without specific symptoms. Our clinical case shows that intrahepatic HCC can disseminate and invade the heart. This aims to highlight the importance of maintaining regular screening TTE for metastases in patients with HCC, so that we can detect the early stagesof the disease and initiatethe treatment