Real-time three-dimensional trans-oesophageal echocardiography: a guidance in challenging endomyocardial biopsy—cardiac angiosarcoma involving upper and lower vena cava

Angiosarcoma, a rare malignant primary cardiac tumour, shows extremely aggressive growth and poor prognosis. Few small population studies are available; therefore, clinical cases add important information to its knowledge. We report a rare case of aggressive angiosarcoma involving both caval veins. A 60-year-old man sought assistance to the emergency department because of chest pain and worsening dyspnoea. Two-dimensional echocardiography (Panel A, subcostal view) showed an isoechoic mass (*) adjacent to right atrium roof, involving inferior vena cava (IVC) outflow tract and associated to pericardial effusion. Cardiac magnetic resonance confirmed transmural invasion of the anterior right atrial wall (Panels B and C). Thus, we performed multisite endomyocardial biopsy, using multiplane trans-oesophageal echocardiographic guidance and a conventional biopsy catheter through trans-femoral approach (Panel D, TE bi-caval view: inhomogeneous mass with irregular profile infiltrating right atrial wall and caval veins). Live 3D trans-oesophageal echocardiography (RT3D TE) provided a real-time navigation through the IVC outflow stenosis due to neoplastic invasion, avoiding bioptome-induced lesions of the free atrial wall [Panels E and F, catheter (▴) coming out from IVC, bioptome (↑) capturing a sample of the mass in right atrium].