A giant, free-floating mass in the left atrium in a patient with atrial fibrillation.

A large intracardiac mass is a rare condition and one with an extremely high risk of haemodynamic and embolic complications. Urgent surgical excision is the treatment of choice, and the histological examination reveals the exact nature of the mass, usually a myxoma or a thrombus. We present the case of an 80-year-old woman, with a history of atrial fibrillation, who was admitted because of a seriously impaired level of consciousness, and fever. A large cerebral infarct and a urinary tract infarction were diagnosed. On the transthoracic echocardiogram a giant, free-floating mass was detected in the left atrium, transiently obstructing the mitral valve orifice. Based on the features of the mass and patient's history, it was considered more likely to be a thrombus rather than a tumour. Given the patient's extremely unfavourable neurological status, cardiac surgery was considered to be contraindicated and the patient was administered unfractionated heparin intravenously. Unfortunately, after a few hours the patient suffered a cardiac arrest and died.

Multiple cardiac metastases from a malignant melanoma.

Metastatic tumors in the pericardium or the heart are more common than primary tumors and their incidence has increased during the last decades due to the prolonged survival of patients with cancer and the increased prevalence of the disease in the general population. We present the case of a 36-year-old patient admitted to our hospital due to fatigue, dyspnea, and episodes of dizziness and fainting during the last month. He had a history of a malignant skin melanoma surgically removed 4 years ago. The echo study identified multiple metastases in the heart involving the pericardium, the myocardium and the right atrium, where the tumor was mobile creating mechanical tricuspid valve stenosis. Malignant metastasis was confirmed by pericardiocentesis and, although treatment with chemotherapy was promptly initiated, the patient died 4 months later. Despite the difficulty in clinical diagnosis of cardiac melanoma, early detection has important therapeutic and prognostic implications. Echocardiography is the most common diagnostic modality and transesophageal approach may be the technique of choice to image intracardiac metastatic tumors.

Exercise testing in asymptomatic patients with heterozygous familial hypercholesterolaemia.

OBJECTIVE: Familial hypercholesterolaemia (FH) is a frequent genetic disorder in Europe, affecting one in 500 people in its heterozygous form. Both homozygous and heterozygous forms are correlated with increased incidence of cardiovascular events. METHODS: We investigated clinical and biochemical parameters possibly associated with the results of exercise testing (ET) in asymptomatic patients with heterozygous FH. The study population was derived from outpatients of the Lipid Center in our department and consisted of 194 patients with heterozygous FH who had no medical history of coronary artery disease (CAD) or angina-like symptoms and who had agreed to undergo ET. RESULTS: Sex, body mass index, smoking status, diabetes mellitus, family history of CAD, presence of xanthomas and total cholesterol, triglyceride, low-density and high-density lipoprotein cholesterol, apolipoproteins A and B and lipoprotein (a) levels did not differ significantly between patients with positive and negative ET. Higher fibrinogen levels, arterial hypertension and family history of CAD were more frequent among patients with positive ET. However, in multivariate analysis adjusted for all the aforementioned variables, only high fibrinogen levels were significantly and independently associated with a positive result of ET. CONCLUSIONS: Lipid and coronary risk factor profiles do not seem to predict exercise-induced myocardial ischaemia in asymptomatic patients with heterozygous FH. However, in this high-risk population for cardiovascular events, fibrinogen levels are an independent predictor of positive ET. The adverse effects of FH on the cardiovascular system may be partly mediated by coagulability factors, whose role in the management of FH patients remains to be fully clarified.