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Goldfinger….
A patient in her early 60s was transferred to our hospital with abdominal pain, blood loss anemia, nausea and vomiting.
Shortly after arrival she suffered PEA arrest. ROSC was achieved within 10 minutes of ACSL and CPR. She was hemodynamically unstable in the MICU.
Surgery was consulted and she was rushed to the operating room for exploratory laparotomy. As part of the resuscitation efforts, we performed intraop TEE.
While the surgeon was exploring the posterior aspect of the stomach, we all of a sudden heard him say "oh, oh…. I think that my finger is in the heart…"

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Gastropericardial fistula is a life-threatening abnormal communication between the stomach and the pericardial sac. It is often deadly. They can present as a very rare cause of severe upper GI bleeding in a patient with previous gastric or esophageal surgery, ulcer perforation or gastric cancer or a combination of the above.
This patient had history of GI bleeding and open gastric bypass surgery.
Communication has been described between the stomach and the left ventricle as well as the right ventricle (rare). They are more prominent in men.
Presentations included chest or left shoulder pain (2/3 of cases), dyspnea, epigastric pain, fever and dysphagia/vomiting/hematemesis/melena.

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Often, "cool images" mean bad things for our patients…

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This patient of ours, who was in his 50s, had history of metastatic melanoma and presented to the hospital with shortness of breath.

In a recent previous admission, he underwent pleurocentesis of the right lung to alleviate shortness of breath. In the more remote past, he had pericardial effusion that required pericardial window.

On this admission, the echo showed tamponade with pericardial mass invading into the RV wall as seen in this SLAX view.

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Melanomas are extremely aggressive tumors that can metastasize to a wide variety of organs, including the heart. While cardiac involvement is frequent, it is usually only diagnosed post-mortem. Initial presentation with cardiac symptoms, without further systemic disease, is uncommon.
The most common presenting symptom of cardiac metastasis is shortness of breath and the most common physical exam finding is tachycardia.
In one series, the most common site of cardiac metastasis is the left ventricle followed by the right atrium.
While cardiac metastases usually tend to remain silent, they can cause:
1. Mechanical complications caused by the limitation of blood flow through the cardiac chambers
2. Electrical complications due to the destruction of the cardiac conduction system by myocardial infiltrative masses
3. Embolization of the tumor, which can mimick TIAs or acute coronary syndrome

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