melanoma remains a public health concern , as incidence continues to rise with mortality remaining stable . a 53-year - old caucasian female was diagnosed with malignant melanoma of the superficial spreading variant on the right shoulder in 1992 ; the tumor , originally 4 cm in diameter , was considered adequately excised along the length of her right shoulder with 3 mm maximal depth . the patient presented to the emergency department complaining of sudden , worsening shortness of breath and palpitations for 5 days . she denied any chest pain , cough , orthopnea or paroxysmal nocturnal dyspnea . on examination , her blood pressure was 123/70 and pulse at 115 beats per minute with respiratory rate at 25 breaths per minute with oxygen saturations at 95% on room air . electrocardiogram ( ecg ) documented upon arrival showed sinus tachycardia with diffuse , low - voltage qrs complexes . blood workup , which included complete blood count , comprehensive metabolic profile , and troponin levels , was within normal limits . chest x - ray found an enlarged cardiomediastinal silhouette with mild pulmonary edema ( fig .  1 ) . a computed tomography angiography ( cta ) of the chest to rule out pulmonary embolism ( pe ) was ordered . after the patient returned from imaging , she was found to have a heart rate of 178 . patient was awake , did not appear to be in any more distress and remained hemodynamically stable . a transthoracic echocardiogram depicted a large mass measuring 5 cm by 7 cm occupying the basal and mid portion of the anterior and lateral walls of the left ventricles with large pericardial effusion located at the lateral posterior wall of the heart , findings suggestive of impending tamponade ( fig .  2 ) . cta of the chest reported no acute pe with a large mass ( 10.5  7.5  9.5 cm ) occupying the anterior wall of the left ventricle and extending to the pulmonary outflow tract ( fig . figure  1:anterior  posterior one view chest x - ray depicting enlarged cardiomediastinal silhouette with mild pulmonary edema . figure  2:transthoracic echocardiogram depicting large effusion within pericardial membrane with left ventricular mass . figure  3:large ventricular mass measuring 10.5  7.5  9.5 cm invading epicardium and myocardium . posterior one view chest x - ray depicting enlarged cardiomediastinal silhouette with mild pulmonary edema . cardiothoracic surgery team was consulted , and the patient underwent a pericardial window with 750 cc of serosanguinous fluid drained from her pericardial space . a chest tube placed status - post pericardial window , which initially continued to drain 500 cc of serosanguinous fluid , with fluid volume decreasing in the following 5 days with stable vital signs . amiodarone and discharged upon her request to restart chemotherapy , after removal of her chest tube . histopathology results of the pericardial fluid were positive for reactive mesothelial cells and chronic inflammation . follow - up positron emission tomography ( pet)/ct scan depicted increased uptake in the cardiac chamber ( fig .  4 ) . repeated echocardiography 2 months later depicted a return in pericardial fluid with the patient remaining hemodynamically stable with preserved ejection fraction . to better stage malignant melanomas , breslow first established a rating system in 1970 to estimate prognoses . his staging system , based on thickness of metastatic tumor and depth of invasion , continues to be of value in assessing prognosis . our patient , having received a breslow depth of 3 mm , qualified for a stage iv ; stage iv 5-year survival rates are 1520% . nearly one - third of all patients diagnosed with metastatic melanoma will experience reoccurrence of their disease . metastatic melanomas are considered common neoplasms having the propensity to metastasize to a multitude of regions , including the heart . for patients with a history of malignant melanomas , up to 71% of them can have some cardiac metastatic involvement , while only 10% of them are actually symptomatic . within the heart , our patient had no right atrium findings ; the mass had invaded both the epicardium and myocardium of the left ventricle . in addition , the patient continued to remain hemodynamically stable despite the large metastatic mass present within her left ventricle . for patients with cardiac metastatic melanoma involvement , hemorrhagic pericardial effusions are often the first presentations of such involvement . utilizing ecgs to detect cardiac involvement may prove futile ; while patients with normal ecgs were less likely to have cardiac metastases , nonspecific st - t wave changes were difficult in differentiating involvement . the typical presentation of cardiac tamponade is hypotension , pulsus paradoxus > 12 mmhg and elevated jugular venous pressures , or alternate - beat variation in the beat , direction , amplitude and duration of a component of the ecg . for our patient , there was difficulty in appreciating ecg findings such as low - voltage or eletricans alternans due to her ventricular tachycardia . for patients with a history of melanoma , metastatic involvement the unique aspect of our case is the length of asymptomatic metastatic growth . for patients with a history of stage iv malignant melanoma , close follow - up should be thoroughly maintained , regardless of symptomatology , to determine if there are any metastases . ecg may not be a reliable source to rule out pericardial involvement as such findings are nonspecific and unreliable and should therefore not be used as the only test to exclude cardiac involvement .
a 53-year - old non - distressed caucasian female complains of dyspnea and palpitations for 5 days . 
 past medical history includes stage iv melanoma with adequate resection 23 years prior . 
 the patient suddenly became increasingly tachycardic in mild respiratory distress while maintaining hemodynamic stability . 
 tte depicted 10.5  7.5  9.5 cm3 mass within her left ventricle and a large volume of pericardial effusion , which progressed to cardiac tamponade . 
 pericardial window was performed . 
 metastatic involvement should be ruled out for all symptomatic patients with a history of melanoma .