European Journal of Echocardiography Advance Access originally published online on April 21, 2008
European Journal of Echocardiography 2008 9(5):725-727; doi:10.1093/ejechocard/jen153
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract
T. Butz1,3,*,
H.K. Schmidt1,
D. Fassbender1,
H. Esdorn2,
M. Wiemer1,
D. Horstkotte1 and
L. Faber1
1 Department of Cardiology, Heart and Diabetes Center North Rhine–Westphalia, Ruhr University Bochum, Georgstr. 11, D-32545 Bad Oeynhausen, Germany
2 Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine–Westphalia, Ruhr University Bochum, Georgstr. 11, D-32545 Bad Oeynhausen, Germany
3 Department of Cardiology and Angiology, Medizinische Klinik II, Ruhr-University Bochum, Hölkeskampring 40, D-44625 Herne, Germany
Received 21 January 2008; accepted after revision 21 March 2008; online publish-ahead-of-print 21 April 2008.
* Corresponding author. Tel: +49 23 234 990. E-mail address: thomas.butz{at}marienhospital-herne.de
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Abstract
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We present the case of a 41-year-old woman who was admitted
to our centre with progressive symptoms of congestive heart
failure (NYHA class III) 5 years after a radical nephrectomy
for renal cell carcinoma. Magnetic resonance imaging demonstrated
a 5
x 3 cm homogeneous intracardial mass causing
right ventricular outflow tract obstruction, not accessible
to surgical resection. Serial echo-guided, percutaneous coil
embolization of the cardial metastasis was performed with Contour
SE Microparticles® (150–250 or 300–500 µm)
after identification of the target region of the metastasis
by contrast injection (Levovist®) through the balloon catheter
into the coronary artery under transoesophageal echocardiographic
control prior to induction of the necrosis, corresponding to
the technique which has been described for septal ablation in
hypertrophic obstructive cardiomyopathy. Follow-up after serial
embolization showed a good haemodynamic and a marked clinical
response (dyspnoea NYHA I–II) which lasted during the
19 month of survival after the index procedure.
Keywords: Renal cell carcinoma; Magnetic resonance imaging (MRI); Echo-guided percutaneous coil embolization; Cardiac metastasis; Tumour
Right ventricular (RV) metastases from renal cell carcinoma
(RCC) without inferior vena cava or right atrium involvement
are exceedingly rare.
1,2
We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for RCC. Computed tomography revealed diffuse hepatic and paraaortic metastases, and a solitary cardiac metastasis in the RV outflow tract. This situation was considered metastatic stage IV RCC, with a usually poor response to immunotherapy and 5-year-survival rate <10%.
Magnetic resonance imaging (MRI) demonstrated a 5 x 3 cm homogeneous mass causing RV outflow tract obstruction, but sparing the pulmonic valve, and infiltration of the aorta and the aortic valve by the metastasis, not accessible to surgical resection (Figures 1 and 2, see Supplementary data online Movie 1). Cardiac catheterization confirmed RV outflow tract obstruction (Figure 3), and demonstrated vascularization of the metastasis by atypical tumour vessels originating from the left anterior descending and the left circumflex artery (Figure 4, see Supplementary data online Movie 2). Serial palliative coil embolization of the metastasis (Contour SE Microparticles®, Boston Scientific; 1–2 ml with 150–250 or 300–500 µm) was performed with an over-the-wire technique. A transit balloon (diameter and length of 2.5 mm/0.4 cm or 2.0 mm/1.0 cm) was placed into the proximal part of the target vessel, inflating the balloon to a pressure of 6–8 bar. The correct balloon position and supply area were determined by contrast injection (Levovist®) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis (Figures 5 and 6A and B, see Supplementary data online Movies 3, 4a and 4b), corresponding to the technique which has been described for septal ablation (PTSMA) in hypertrophic obstructive cardiomyopathy (HOCM).3,4 Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I–II) which lasted during the 19 month of survival after the index procedure.
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Figure 1 Magnetic resonance imaging (MRI) (1.5 Tesla, darkblood technique, transversal axis) demonstrating the metastasis (asterisk) in the right ventricular outflow tract, and infiltration of the aorta and the aortic valve (AV).
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Figure 5 After the balloon was inflated to a pressure of 6–8 bar, the correct balloon position and supply area were determined by contrast injection through the balloon catheter into the coronary artery prior to induction of the necrosis (RAO 38°, CAUDAL 14°)
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We conclude that solitary cardiac metastasis causing important
haemodynamic impairment may be treated palliatively in selected
patients by selective, echo-guided coil embolization. Life-threatening
complications of this procedure like myocardial infarction due
to embolization of a coronary artery should be discussed with
the patient before the procedure.
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Supplementary data
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Supplementary data are available at European Journal of Echocardiography online.
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References
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- Atik FA, Navia JL, Krishnamurthi V, Singh G, Shiota T, Pitas G, et al. Solitary massive right ventricular metastasis of renal cell carcinoma without inferior vena cava or right atrium involvement. J Card Surg (2006) 21:304–6.[CrossRef][Web of Science][Medline]
- Santo-Tomas M, Mahr NC, Robinson MJ, et al. Metastatic renal cell carcinoma invading ventricular myocardium without caval involvement. J Card Surg (1998) 39:811–2.[Web of Science]
- Faber L, Seggewiss H, Gleichmann U. Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: results with respect to intraprocedural myocardial contrast echocardiography. Circulation (1998) 98:2415–21.[Abstract/Free Full Text]
- Faber L, Seggewiss H, Ziemssen P, Gleichmann U. Intraprocedural myocardial contrast echocardiography as a routine procedure in percutaneous transluminal septal myocardial ablation: detection of threatening myocardial necrosis distant from the septal target area. Catheter Cardiovasc Interv (1999) 47:462–6.[CrossRef][Web of Science][Medline]
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