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Objective: We present a rare case of isolated metastasis to the right ventricle (RV) from hepatocellular carcinoma (HCC) for which he underwent a left hepatectomy a few years earlier.

Methods: 71 year old man presented with an episode of atypical chest pain. He had extended left hepatectomy with caudate lobectomy for hepatocellular carcinoma 3 years ago, with no evidence of recurrence on restaging scans 1 year ago. ECG revealed sinus rhythm with new right bundle branch block and stress test with anterior ischemic, affixed inferoseptal defect and inferior ischemia. TTE showed a normal EF but a large RV mass. His Hepatitis panel, CEA and AFP were negative. CT chest showed a 8 x 5 x 4.5 cm mass involving the anterior wall of the RV, extending from the level of the outflow tract to the apex. CT abdomen/pelvis showed no evidence of recurrent or metastatic disease. Cardiac Catheterization showed Right Coronary Artery (RCA) with ostial and proximal 80% lesions just prior to a large saccular aneurysm arising from the proximal vessel. MRI revealed a large hypervascular 7 x 5 x 4.5 cm enhancing RV mass involving approximately 50% of the RV free wall and the entire anterior wall. There was 50% invasion of the interventricular septum with slight narrowing of the RV outflow tract without hemodynamically significant obstruction.

Results: The patient underwent debulking of RV mass, intracardiac excisional biopsy of RV mass, plication of RCA aneurysm, and coronary artery bypass grafting x1 with reverse saphenous vein graft to the distal RCA. The tumor was only debulked because it was of metastatic origin on frozen section and occupied approximately two thirds of the anterior wall of the right ventricle, straddled the intraventricular septum and encased the midportion of the LAD coronary artery for a length of about 8 cm, and extended onto the left ventricle for about 2 cm. He had uncomplicated recovery and was discharged on day 7 in good condition to follow up with his oncologist for further treatment of the residual RV tumor.

Conclusions: HCC tend to metastasize to the lungs, bones, and abdominal organs much more frequently. There is no reported case in literature of HCC metastasizing to the heart in association with RCA aneurysm.