Journal of ISSN: 2373-4396JCCR

Cardiology & Current Research
Case Report
Volume 3 Issue 1 - 2015
Elevated Carbohydrate Antigen 125 Level in a Patient with Right Heart Failure
Marwan Refaat1*, Mostafa Hotait1, Anthony L Innasimuthu2 and Barry London3
1Department of Internal Medicine, American University of Beirut - Medical Center, Lebanon
2Division of Cardiovascular Medicine, State University of New York- Downstate Medical Center, USA
3Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, USA
Received: March 11, 2015 | Published: July 21, 2015
*Corresponding author: Marwan M Refaat, Assistant Professor of Medicine, Department of Internal Medicine, Cardiology/Cardiac Electrophysiology, American University Medical Center, Beirut, Lebanon, Tel: +961-78-929290; Email: @
Citation: Refaat M, Hotait M, Innasimuthu AL, London B (2015) Elevated Carbohydrate Antigen 125 Level in a Patient with Right Heart Failure. J Cardiol Curr Res 3(1): 00092. DOI: 10.15406/jccr.2015.02.00092

Abstract

Carbohydrate antigen 125 is a known marker for ovarian cancer. A unique case of elevated carbohydrate antigen 125 in a patient with rheumatic heart disease, preserved left ventricular function and isolated right heart failure is reported.

Keywords: Heart failure; Rheumatic heart disease; Right ventricle; CA 125

Introduction

Serum CA125, a high-molecular weight glycoprotein, is a tumor marker widely used for the diagnosis and follow-up of patients with ovarian cancer. Recent studies have shown that CA125 is elevated in heart failure (HF) patients demonstrating a strong correlation with the clinical and echocardiographic findings. We report a case of elevated carbohydrate antigen 125 in a patient with right heart failure due to rheumatic heart disease.

Case Report

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/m2. 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.

Discussion

The 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 patients with COPD even before corpulmonale to be evident [5]. Our report adds to the literature a unique case that describe CA 125 elevation in a patient with isolated right heart failure in the setting of rheumatic heart disease [6,7]. Though the exact mechanism remains unclear, the production of CA 125 is hypothesized to be increased secretion by the peritoneal mesothelium, either via a direct stretch activation due to the as cites from the right heart failure or via an indirect activation through inflammatory cytokines such as interleukin-6 [8]. Furthermore, the increased pro-inflammatory state in heart failure likely increases the production of CA 125 from the pericardium as well. In addition, stretching of the pericardium from the dilated heart chambers will likely lead to increased secretion of CA 125 from the visceral pericardial epithelial cells. This is a similar process to the stretching of the myocytes that leads to secretion of brain natriuretic peptide from the ventricles of the heart. It is important to recognize that benign conditions such as isolated right heart failure can result in markedly elevated CA 125 level.

Conclusion

Our patient presented with symptoms suggestive of volume overload. During initial investigation, it was found that her CA 125 was elevated and after her CHF was appropriately treated and her symptoms were resolved, CA 125 returned back to baseline. Various mechanisms have been hypothesized to explain the association between volume overload/heart failure and CA-125 elevation. In this sense, it is important to recognize that benign conditions such as isolated right heart failure can result in markedly elevated CA 125 level. Further studies are necessary to confirm the sensitivity and specificity and to see if it could be a predictor of mortality and morbidity or used in risk stratification of patients with CHF.

References

  1. Sjovall K, Nilsson B, Einhorn N (2002) The significance of serum CA 125 elevation in malignant and nonmalignant diseases. Gynecol Oncol 85(1): 175-178.
  2. Nägele H, Bahlo M, Klapdor R, Schaeperkoetter D, Rödiger W (1999) CA125 and its relation to cardiac function. Am Heart J 137(6): 1044 -1049.
  3. Núñez J, Núñez E, Consuegra L, Sanchis J, Bodí V, et al. (2007) Carbohydrate antigen 125: an emerging prognostic risk factor in acute heart failure? Heart 93(6): 716-721.
  4. D'Aloia A, Faggiano P, Aurigemma G, Bontempi L, Ruggeri G, et al. (2003) Serum levels of carbohydrate antigen 125 in patients with chronic heart failure: relation to clinical severity, hemodynamic and Doppler echocardiographic abnormalities, and short-term prognosis. J Am Coll Cardiol 41(10): 1805-1811.
  5. Yilmaz MB, Zorlu A, Dogan OT, Karahan O, Tandogan I, et al. (2011) Role of CA-125 in identification of right ventricular failure in chronic obstructive pulmonary disease. Clin Cardiol 34(4): 244-248.
  6. Mathew B, Bhatia V, Mahy IR, Ahmed I, Francis L (2004) Elevation of the tumor marker CA 125 in right heart failure. South Med J 97(10): 1013-1014.
  7. Lockhart CJ, McVeigh GE, Harbinson MT (2008) Elevated CA 125 and ascites: not always malignancy. Ir J Med Sci 177(1): 63-66.
  8. Vizzardi E, D'Aloia A, Pezzali N, Bugatti S, Curnis A, et al. (2012) Long term Prognostic Value of CA 125 Serum Levels in Mild to Moderate Heart Failure Patients. J Card Fail 18(1): 68-73.
© 2014-2016 MedCrave Group, All rights reserved. No part of this content may be reproduced or transmitted in any form or by any means as per the standard guidelines of fair use.
Creative Commons License Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at http://medcraveonline.com
Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version | Opera |Privacy Policy