Eisenmenger syndrome and endometrial carcinoma: a cardio-oncologic therapeutic dilemma: case report

Eisenmenger syndrome (ES) represents the end stage of uncorrected congenital heart defects with long-standing left-to-right shunts that evolve into irreversible pulmonary vascular remodelling and pulmonary arterial hypertension. This report highlights the complex cardio-oncological management of a patient with ES and chronic thromboembolic pulmonary hypertension (CTEPH), who developed endometrial carcinoma complicated by life-threatening uterine bleeding.

A 66-year-old woman with an uncorrected ostium secundum atrial septal defect complicated by Eisenmenger physiology and CTEPH presented with vaginal bleeding. She was diagnosed with endometrioid adenocarcinoma. Due to prohibitive surgical risk, radiotherapy was selected as the primary treatment; however, bleeding persisted despite completion of 28 sessions. Interruption of warfarin therapy was contraindicated, given her high thrombotic risk. Following multidisciplinary team deliberation, uterine artery embolization (UAE) was performed successfully, achieving haemorrhage control without major haemodynamic instability. This minimally invasive intervention proved life-saving in a patient for whom both surgical and medical alternatives carried unacceptable risk.

The case exemplifies the intricate balance between anticoagulation and haemorrhagic control in ES complicated by malignancy. Severe hypoxaemia and haemostatic abnormalities inherent to ES amplify both bleeding and thrombotic risks, complicating oncological management. Tumour hypoxia secondary to chronic cyanosis may contribute to radioresistance and poor response to local therapy. The successful use of UAE underscores the vital role of a multidisciplinary cardio-gynaecology-oncology team in navigating life-threatening clinical conflicts and tailoring individualized strategies when conventional guidelines offer limited direction.