A 55 year old man was admitted to hospital after collapsing while playing golf. During assessment in the emergency department the patient became unconscious and lost cardiac output associated with a sinus bradycardia of 40 beats/min, some non-specific changes in the inferior ECG leads, and normal myocardial injury markers. Coronary angiography demonstrated normal coronary arteries; however, a branch of the right coronary artery (RCA) supplying the right atrium (RA) was associated with a tissue blush (panel A). Transthoracic echocardiography (TTE) confirmed a mass in the RA and a global pericardial effusion (panel B). Transoesophageal echocardiography (TOE) showed a localised 3.5 × 3.5 cm tumour of the RA anterior wall (panel C). A computed tomographic (CT) scan of the chest showed no evidence of metastasis. Operative findings showed extension of the tumour to the surface of the RA and involvement of the RCA. The tumour was resected and a saphenous vein graft was anastomosed to the distal RCA. Histology confirmed angiosarcoma with a high mitotic rate and incomplete resection at the margin. A repeat operation with wider excision was performed with a clear histological margin. Five cycles of doxorubicin and ifosfamide chemotherapy were administered. Adjuvant radiotherapy to the site of the primary tumour was given. The patient died 11 months after primary diagnosis from CT proven metastatic disease.

This case demonstrates the unusual angiographic findings of a cardiac malignancy and its correlation with TTE and TOE echocardiographic images.

A tumour blush in the right atrium is seen during right coronary angiography.

Transthoracic echocardiogram demonstrating a mass in the right atrium.

Transoesophageal echocardiogram clearly showing the tumour and its extension.