Elevated Carbohydrate Antigen 125 Level in a Patient with Right Heart Failure

Abstract

A 55-year-old woman with history of rheumatic heart disease, mitral valve and aortic valve replacement four months ago was admitted with dyspnea, abdominal distention and swelling in her lower extremities. Her physical examination was remarkable for ascites and bilateral pedal edema. A chest roentogram showed a small right pleural effusion. Her electrocardiogram was consistent with sinus bradycardia. Her echocardiogram showed a normal left ventricular function with an ejection fraction of 55-60%, moderate pulmonary hypertension, moderately dilated right ventricle with moderately decreased function, moderate tricuspid regurgitation, moderate to severe pulmonic regurgitation, moderate right atrial enlargement and mild left atrial enlargement. Her right heart catheterization showed a right atrial pressure of 28 mmHg, a right ventricular end diastolic pressure of 31 mmHg, a pulmonary artery pressure of 92/36 mmHg, a mean pulmonary artery pressure of 68 mmHg, pulmonary capillary wedge pressure of 22 mmHg, a pulmonary artery saturation of 33% and a cardiac index of 1.7 L/min/m 2 . During initial investigation, it was found that her carbohydrate antigen (CA) 125 was markedly elevated to 871 U/ml (upper normal level is 35 U/ml). Investigation for gynecological malignancy by ultrasonography and computer tomography of the abdomen and pelvis was negative. Her ascites was tapped and the analysis did not show any malignant cells. She was started on diuretics and ionotropes with clinical improvement. Her symptoms were resolved and there was no evidence of abdominal distention on exam after few days of hospitalization. Since no obvious malignancy could be identified, her CA 125 was repeated and it was 35 U/ml. DiscussionThe CA 125 is a high molecular weight (approximately 2-5 million daltons) glycoprotein synthesized by epithelial serosal cells, such as the pleura, pericardium and peritoneum [1]. Inflammation or stretch of the serosal surface may be responsible for elevation of CA 125. The biological role of CA 125 in humans is not clearly understood. CA 125 is a tumor marker that is used in ovarian cancer. It has been shown to be useful for diagnosis of suspected cases, to monitor the efficacy of treatment and for early detection of recurrence. Increased CA 125 has also been noted in other neoplastic diseases like lung, breast, uterine and gastrointestinal tract cancer and non-neoplastic diseases like liver cirrhosis, serosal effusion and renal impairment [1]. Nagele et al. [2], while measuring various biomarkers in HF patients, were the first to identify this strong correlation between elevated CA 125 level and the severity of the clinical picture of patients [2]. Other studies investigated the evidence of this correlation in acute failure cases and right-sided failure cases [3,4]. D' Aloia et al. [4] showed a significant correlation of CA 125 levels with the right atrial and systolic pulmonary artery pressure. In a different study by Yilmaz et al. [5], elevated levels of CA 125 reflected right ventricle dysfunction in patie...