A Case of Right Ventricular Mass Presenting with Right Ventricular Outflow Tract Ventricular Tachycardia

Abstract

Cardiac metastasis due to primary lung lesion is a rare entity. The involvement of endocardium is very unusual. Moreover, cardiac metastasis may present is different ways. Here we present a case of a male in his sixth decade who presented with right ventricular outflow tract ventricular tachycardia. On examination, a cardiac metastasis in endocardium of primary lung origin was observed. A 62-year-old male was admitted with history of recurrent episodes of palpitation, perspiration and chest pain since 2 months. On admission, electrocardiogram was done which showed monomorphic ventricular tachycardia with LBBB and inferior axis was suggestive of right ventricular outflow tract ventricular tachycardia (RVOT-VT) (Figure 1). Immediately synchronised DC shock was used to cardiovert to normal sinus rhythm. He had no family history of QT prolongation, arrhythmia or sudden cardiac death. He was evaluated with 2D-Echocardiography which showed large echogenic mass on right ventricular wall extending up to RVOT. It was adherent to myocardium, sessile with rough borders. It raised a suspicion of tumour or metastasis of right ventricle. In view of RVOT-VT we started metoprolol 25 mg twice daily. Chest X-ray and ultrasonography was normal. Coronary angiography was normal. Cardiac MRI showed a 62 x 26 mm well defined lesion with central necrosis involving anterior wall of right ventricle with post contrast enhancement which was suggestive of neoplastic mass (Figure 2). There was an ill-defined soft tissue lesion with post contrast enhancement in left lower lobe of lung which was likely to be primary or secondary neoplastic lesion. As RV free wall mass was easily approachable to endomyocardial biopsy, we planned the same and took multiple endomyocardial biopsies which were sent for histopathology and immunohistochemistry. Histopathological report showed intermediate grade fibrosarcoma or malignant fibrohistiocytic tumour. When the patient was informed about his condition, he denied treatment for metastasis and subsequently he succumbed after one month of diagnosis.