PMC9780589_01
Electrocardiogram. Panel (A) shows tall R waves and giant-negative T waves in V4-V6. Panels (B) (8 months later) and (C) (24 months later) show a progressive decrease in the amplitude of the R waves and T wave inversions in the paced beats in precordial leads.
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The initial 12-lead electrocardiogram showed demand ventricular pacing with underlying atrial fibrillation, left ventricular (LV) hypertrophy, and giant negative T waves in paced as well as normally conducted beats (Figure 1A), and a transthoracic echocardiogram (TTE) showed apical hypertrophy. The subsequent 12-lead electrocardiograms showed a decreasing amplitude of T wave inversions and R waves over time in the paced beats (Figures 1B,C). CT-guided biopsy of the pulmonary nodule confirmed the metastatic spread of the melanoma to the lungs (see Supplementary Figure 1).
Transthoracic echocardiogram. The apical four-chamber view (A) (Supplementary Video 1), apical long-axis view (B) (Supplementary Video 2), and definity contrast echocardiogram (C) (Supplementary Video 3) show apical wall thickness (yellow arrows). Panel (D) shows strain analysis with markedly reduced peak systolic strain and evidence of dyskinesis in the apical segments.
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TTE showed an apical wall thickness of 19 mm (Figure 2; Supplementary Videos 1-3). The global longitudinal strain was reduced to -9% and the LV ejection fraction was 70%.
Chest CT and PET scan. Computed tomography (CT) showing metastatic melanoma involving the left ventricular apical wall (A), left lung (B), and positron emission tomography (PET) scan axial image (C) showing increased fluorodeoxyglucose uptake in the left ventricular apex (arrow) and left lung (arrow heads). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
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T4B N0 M0, stage II-C melanoma. The chest computed tomography (CT) s162can showed nodular thickening of the LV apex and pulmonary nodules in the left lung, suggestive of metastatic disease (Figures 3A,B). A positron emission tomography (PET) scan revealed increased uptake of fluorodeoxyglucose (FDG) in the LV apex and left lung nodules (Figure 3C), suggestive of metastatic spread of the melanoma to the LV apex and left lung.