primary tumors of the heart are rare , with a prevalence of 0.001 - 0.03% in an autopsy series.1 ) approximately 75% of primary cardiac tumors are benign , with cardiac myxomas accounting for > 50% of benign cardiac tumors . hepatocellular carcinoma ( hcc ) is the most common primary malignant tumor of the liver . the most common sites of hcc metastasis are the lungs , followed by the regional lymph nodes and adrenal glands.2 ) the heart is an uncommon site for hcc metastasis with the right atrium ( ra ) the most common site.3 - 5 ) surgical treatment of metastatic hcc is generally performed for symptomatic patients . we recently managed a patient with metastatic hcc in the ra , left atrium ( la ) , and left ventricle ( lv ) who underwent an emergent tumorectomy for symptomatic relief . a 48-year - old male was admitted to our hospital for evaluation of a left pleural effusion demonstrated by ct scan 1 day earlier . twenty - nine months earlier , he had been diagnosed with hcc with lung metastasis , for which he had received chemoembolization 11 times . nevertheless , a ct scan performed 3 months ago showed tumor thrombi within the right hepatic vein ( rhv ) , inferior vena cava ( ivc ) , and ra ( fig . 1 ) . on hospital day 2 , a sonography - guided left thoracentesis was performed . the laboratory data for the pleural fluid was as follows : lactate dehydrogenase , 312 u / l ; white blood cell , > 1,000/ul ; and polymorphonuclear leukocytes , 40% . a chest x - ray revealed bilateral lower lung haziness , consistent with a pneumonia , thus antibiotics were started . a ct scan was obtained 1 day prior to admission and demonstrated intracardiac tumor thrombi of the ivc , ra , and la ( fig . transthoracic echocardiography ( tte ) revealed a la thrombus obstructing the mitral valve ( fig . we thus performed an emergent left atrial tumorectomy with the use of cardiopulmonary bypass ( cpb ) and a large tumor thrombus was extracted ( fig . 4 ) . in the operating room , we applied cpb quickly because of unstable vital signs . after the left atriotomy was performed , we easily identified a large ( 544 cm ) , multi - lobulated , firm mass . the mass originated from the left pulmonary veins and protruded to the entire mitral valve orifice , but definite invasion into the mitral valve was not present . after confirmation , we extracted the mass at the origin of the pulmonary vein as much as possible . then , we confirmed pulmonary venous return flow . during surgery , we had to reduce the cpb time ( 145 minutes ) and aortic cross - clamp time ( 53 minutes ) because of related co - morbidities . therefore , we left the ra mass in situ , which did not cause symptoms of ivc obstruction . on pathologic examination of the specimen , we demonstrated metastatic hcc with necrosis and an organizing hematoma . in addition , follow - up echocardiography also demonstrated absence of the left atrial mass ( fig . however , during the immediate post - operative period , acute renal failure developed and he received continuous renal replacement therapy in the intensive care unit . after he recovered from the renal failure , he received chemotherapy ( 5-fluorouracil and mitomycin - c ) . he was discharged with no dyspnea on hospital day 54 and lived a life without recurrence of the symptoms associated with mitral valve obstruction until the last outpatient follow - up , which was done 5 months post - operatively . however , 1 week after the last follow - up , he was admitted to our hospital complaining of hematemesis and melana . metastatic cardiac tumors are 20 - 40 times more common than primary cardiac tumors.1 ) the most common malignancy that involves the heart is lung , followed by lymphoma , breast , leukemia , stomach , melanoma , liver , and colon.6 ) extrahepatic metastasis is frequent in advanced hcc , and the prognosis is poor . the common metastatic sites for hcc are the lung , regional lymph nodes , adrenal glands , peritoneum , and bones.2)7 ) although hcc is prone to vascular invasion and extension , metastasis to the cardiac cavity is very rare.8)9 ) kojiro et al . in addition , intracavitary metastasis occurs mostly in the ra,3 - 5 ) with few reports of other cardiac chamber involvement.10 - 12 ) two - dimensional echocardiography is considered to be the most important primary screening imaging modality for cardiac tumors.13 ) tte reveals tumor size , location , mobility , and associated findings . although tte remains the initial diagnostic tool , transesophageal echocardiography ( tee ) affords more detailed and accurate information . matsumura et al.14 ) showed that tee is superior to tte in detecting cardiac masses , recognizing abnormal flow , and estimating the anatomic relationship between tumors or thrombi and cardiac structures . moreover , tee provides better resolution because it is closer to the heart and uses a higher frequency transducer . we did not perform tee because there was sufficient information regarding the hcc by tte and ct . ct is a superior modality for demonstrating the morphology , location , and extent of cardiac tumors . the advantage of ct over echocardiography is the ability to characterize the lesions and evaluate the pericardium , great vessels , and extracardiac structures , which makes it possible to delineate the extent of tumor involvement.1)15 ) in addition , ct provides the opportunity to investigate mediastinal structures , including lymph nodes , which could be involved in cases with cardiac tumors.16 ) ct images are also present in several formats , including traditional transverse , coronal images and sagittal images . thoracic ct and echocardiography provided the diagnosis of cardiac metastasis , including the ra , la , and lv . generally , surgical treatment is not an option for metastatic tumors , and is rarely performed.17 ) this is true for hcc . surgical resection is reserved for symptomatic patients due to poor prognosis , i.e. , short life expectancy and the inability to perform a radical excision . in addition , there is concern about systemic spread of cancer during cpb surgery.18 ) in spite of these concerns , surgical resection should be considered when palliative symptom relief is needed . in our case , this aim was accomplished uneventfully . chemoembolization is an alternative strategy for cardiac metastasis.19)20 ) however , systemic chemotherapy is a disappointing treatment strategy , which has yielded lower response rates for hcc ( < 20%).2 ) in conclusion , we report a patient with cardiac metastasis from hcc , who was treated by palliative surgical resection because of life - threatening dyspnea , followed by chemotherapy . based on our case , it would be worthwhile to mention two points which would be helpful in treating similar patients : 1 ) echocardiography and ct are useful tools to find cardiac metastasis in case of hcc ; 2 ) although surgical resection is generally not indicated due to poor prognosis for hcc , it could be a better alternative to conservative management or chemoembolization for relieving life - threatening symptoms .
hepatocellular carcinoma ( hcc ) with metastasis to the heart is uncommon . 
 we report a rare case of left atrial metastasis of hcc which was resected palliatively as a live - saving procedure with the use of cardiopulmonary bypass . despite chemoembolization , which was undertaken 11 times , 
 cardiac metastasis occurred . 
 moreover , the right and left atria and left ventricle were involved simultaneously . 
 the severe dyspnea improved dramatically after surgery . following this , the patient underwent systemic chemotherapy and lived a life without recurrence of symptoms associated with mitral valve obstruction .