cardiac angiosarcoma
Description
Patient: female, age 65.
Previous medical history:
Hodgkin's lymphoma, which was treated with chemotherapy, high-dose mantle radiation, and surgery.
scleroderma mild.
Tamponade-related prior pericardial effusion → pericardial window.
Atrial fibrillation that is paroxysmal.
Symptoms:
include palpitations, shoulder soreness, lower extremity oedema, and progressive dyspnoea with effort.
Initial suspicion:
Constrictive pericarditis (caused by radiation treatment or an inflammatory condition) is the first suspect.
Investigations:
Echocardiography
Decreased RV function and maintained LV function.
Septal bounce and flattening.
Thickness of the pericardium (0.8 cm).
Little, localised effusion.
Constrictive physiology due to a substantial respirophasic change in transmitral flow.
MRI of the heart
Pericardium thickened widely (0.7–0.8 cm).
Enhancement of the pericardium (indicative of inflammation or pericarditis).
Eexcessive mobility of the septum (supportive of constriction).
Catheterisation of the Heart
Kussmaul's sign (inspiration-induced increase in SVC pressure).
W-pattern with noticeable x and y descents is the RA pressure.
RV waveform:
Square root sign with dip-and-plateau.
Concurrent LV and RV pressures: ventricular interdependence, or systolic discordance with inspiration.
Every one of them is in line with constrictive physiology.
CT chest (pre-operative)
Thickening of the circumferential nodular pericardium.
Mass-like region in the mediastinum on the left.
Discussion / Learning
Cardiac angiosarcoma
The most prevalent primary malignant heart tumour, but extremely uncommon.
0.0002–0.03% (autopsy) is the incidence.
Risk elements:
Exposure to vinyl chloride and mediastinal radiation.
Dyspnoea, chest discomfort, malaise, recurrent pericardial effusions, and pericarditis are examples of non-specific symptoms.
Metastatic at diagnosis is common.
Difficult to diagnose:
Pericardial fluid often negative for malignant cells.
There might not be any bulk on echocardiography.
Prognosis
With a typical survival of 6–14 months, the prognosis is poor.
Treatment options: Surgery usually limited by invasion.
Chemotherapy (docetaxel with gemcitabine, dacarbazine, vincristine, cyclophosphamide, ifosfamide, and Adriamycin).
The effectiveness of radiation treatment is limited.
There have been heart transplants, but the results are not good.
Protocol
Management
In this rare case, cardiac angiosarcoma manifested as constrictive physiology, making management particularly difficult and requiring a multidisciplinary approach. Here is a comprehensive analysis of the issues encountered, and the methods employed to address them, highlighting the medical and nursing actions taken during the patient’s experience.
Challenges Encountered
Gradual shortness of breath during physical activity
Significant pericardial effusion with tamponade
Ongoing palpitations and continual atrial fibrillation
Deteriorating signs of heart failure (fluid overload, swelling)
Severe gastrointestinal hemorrhage during chemotherapy
Emotional supportive care requirements arising from unfavorable prognosis.
Management Strategies
Effusion Control and the Pericardial Window
Tamponade was treated with emergency pericardial window surgery.
Colchicine was initiated to treat pericardial irritation, and fluid testing was used to rule out infection or cancer.
Identification and Multimodal Imaging
Constrictive physiology was discovered by cardiac MRI, cardiac catheterisation, and echocardiography. Later, a mass enclosing the heart was discovered.
Medical Treatment :
Mycophenolate mofetil, prednisone, and colchicine are being tested for a possible autoimmune or pericardial inflammatory cause.
Amiodarone is used to treat atrial fibrillation after surgery.
Management of Heart Failure
Bumetanide-assisted aggressive IV diuresis to treat post-operative heart failure symptoms and chronic volume overload.
Surgical Procedure:
A pericardiectomy was undertaken, however the tumour was discovered to be inoperable since it had invaded. Angiosarcoma was verified by pathology.
Cancer Therapy:
Gemcitabine and docetaxel were used to start the chemotherapy, which was postponed until the wound healed from surgery.
One of the side effects of chemotherapy was gastrointestinal bleeding, which needed immediate attention.
Nursing interventions:
-Acute Symptom Monitoring and Response
- Constant monitoring of vital signs, electrocardiogram, and fluid balance for increasing dyspnoea, arrhythmias, and
volume status.
- Early identification and treatment escalation during acute decompensation and tamponade events.
- Supporting Medication and Therapy Administration
- Colchicine, corticosteroids, immunosuppressants, and IV diuretics should be administered precisely while being closely watched for adverse effects and efficacy.
- Anticoagulation and the treatment of arrhythmias, especially atrial fibrillation following surgery.
- Complication Prevention and Management
- Monitoring for infection symptoms both during immunosuppressive treatment and after surgery.
- Control and prompt action for bleeding brought on by chemotherapy.
- Preventing pressure sores and falls when immobilised.
- Emotional, Psychosocial and Palliative Support
- Discussion of the diagnosis, prognosis, and treatment objectives.
- Psychological assistance to the patient and their family, particularly while they are switching to comfort care.
Notes
For more information visit https://pmc.ncbi.nlm.nih.gov/articles/PMC7403564/
