Acute right ventricular failure in a patient with hepatic cirrhosis

Abstract

Pulmonary embolic disease is most commonly a manifestation of venous thromboembolism (VTE). However, fat, tumor, and air may all embolize to the pulmonary vasculature and lymphatics resulting in various clinical manifestations. Tumor emboli to small pulmonary vessels and lymphatics can lead to hypoxemic respiratory failure and shock. We present a 62-year-old male with history of mild COPD and end-stage liver disease secondary to hepatitis C admitted due to progressive shortness of breath and hypoxemia who developed shock and right ventricular failure. After a negative evaluation for venous thromboembolic disease, he had progressive respiratory and hemodynamic deterioration despite mechanical ventilation, renal replacement therapy, and vasopressive/inotropic support. Postmortem examination revealed diffuse micronodular moderately differentiated hepatocellular carcinoma (HCC) without a discrete mass, as well as numerous HCC tumor emboli to the lung and focally to the heart, consistent with disseminated hepatocellular tumor microembolism.

Figure 1

Increased interstitial markings bilaterally and right hemidiaphragm elevation.

Figure 2

Low probability for venous thromboembolism.

Figure 3

Systolic apical 4-chamber view with normal-sized left ventricle on the left and markedly dilated right ventricle on the right, (b) Parasternal short-axis view of left ventricle shows “D-shaped” left ventricle indicating right ventricular pressure overload and markedly dilated and thin-walled right ventricle on the top.

Figure 4

Cirrhotic liver with numerous HCC micronodules (arrow).

Figure 5

Numerous capillary and lymphatic HCC tumor emboli (arrow).

Figure 6

Lung tissue with intravascular tumor. Focal bile consistent with HCC (arrow).