Inferior STEMI in a Patient With Cardiac Metastasis

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  Visual Summary. Timeline of Presentation Patient was diagnosed with squamous cell lung cancer 1 year before presentation and was found to have an intracardiac mass on imaging in the months leading to presentation. At presentation, she was found to have STEMI findings without signs of obstruction on coronary catheterization. Throughout her hospital course, she developed intermittent symptomatic atrial fibrillation and eventually elected for a comfort-focused approach with symptom improvement. She passed away peacefully 12 days after presentation. CT = computed tomography; DNR/DNI = do not resuscitate/do not intubate; MRI = magnetic resonance imaging; PET = positron emission tomography; RVR = rapid ventricular response; STEMI = ST-segment elevation myocardial infarction; TTE = transthoracic echocardiography.

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  Figure 1. Admission Electrocardiogram Electrocardiogram on admission showing sinus bradycardia; 2-mm ST-segment elevations in leads II, III, aVF, V3, and V4; and 1-mm ST-segment elevations in V5 and V6 with ST-segment depressions in aVL.

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  Figure 2. Echocardiogram Before Hospitalization Transthoracic echocardiogram apical 4-chamber view 4 months before hospitalization showing a mobile, partially calcified mass attached to the posteromedial papillary muscle with frond-like appendages and independent motion. Thrombus was included on the differential, but was felt to be less likely in the setting of normal adjacent wall motion. The red arrow denotes the location of the echodensity.

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  Figure 3. Magnetic Resonance Imaging Before Hospitalization (A) Transverse and (B) sagittal views of cardiac MRI 2 months before admission showing normal biventricular size and function with an intracardiac mass in the left ventricle in the inferoseptum, officially measured at 32.4 × 45.3 mm. The red arrow denotes the location of the mass. MRI = magnetic resonance imaging.

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  Figure 4. Full-Body Positron Emission Tomography Scan PET/CT of skull base to mid-thigh 2 months before admission, showing uptake of tracer in a centrally necrotic lesion in the left ventricle (red arrow). PET/CT = positron emission tomography/computed tomography.

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  Figure 5. Coronary Angiography Findings Imaging of RCA during coronary angiography showing mild diffuse (≤25% stenosis) disease of the entire segment. (A) Left anterior oblique view, (B) right anterior oblique view. RCA = right coronary artery.

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  Figure 6. Echocardiogram Findings Echocardiogram apical 4-chamber view showing a large echodense structure measuring 4.4 × 2.2 cm affixed to the inferior septal wall from the base to the midsegments, protruding into the left ventricular cavity. The red arrow denotes the location of the structure.

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  Figure 7. Electrocardiograms Throughout Admission Serial electrocardiograms taken throughout the hospital course. (A) Hospital day 2 showing atrial fibrillation with rapid ventricular response (ventricular rate: 144 beats/min) with premature ventricular or aberrantly conducted complexes and persistent ST-segment elevations in the inferior lateral leads. (B) Hospital day 6 with increased ST-segment elevations in the inferior lateral leads in V3 and V4 with ongoing changes in V5 and V6. (C) Hospital day 8 showing atrial fibrillation with rapid ventricular response and a ventricular rate of 133 beats/min.

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  Figure 8. Full-Body Computed Tomography Scan Findings Hospital day 8 CT scan showing extent of cardiac metastases, denoted by red arrows. (A) Enlarging metastasis centered on the intraventricular septum measuring 5 × 6 × 7 cm, previously up to 5 cm. (B) Second metastasis along left ventricular free wall measuring 1.5 cm. (C) An additional metastasis on the left ventricular apex adjacent to the mitral annulus and left ventricular outflow track measuring 2.6 cm. CT = computed tomography.