**4. Metastatic cardiac tumors**

Metastatic tumors are 20 to 40 times more common than primary malignant ones with prevalence of 6% in post-mortem autopsies in malignant diseases (6).

#### **4.1 Malignant melanoma**

For the first time the term "melanotic heart" was introduced by William Norris in 1820 (7). However, many cases of malignant melanoma have been described in scientific literature.

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Malignant melanoma frequently (50-71%) metastasizes to the heart (19). It seems to have the highest rate of metastases to heart. When a patient presents with cardiac metastases of melanoma, the disease has already spread throughout the body and is rarely curable (20). Single metastasis is rare. Metastases could be found in right side or left side; however, bilateral metastasis is frequently seen (21). The way of tumor spread toward heart is mostly hematogenous as seen in lymphoma and leukemia.

Previously, histologic diagnosis of malignant melanoma was made postmortem; however, with early detection of metastases due to availability of new imaging modalities, definite antemortem diagnosis and pathologic examination is frequently possible. Tissue specimen can be obtained by echocardiography guided transvenous biopsy or by resection of mass (22).

The symptoms are nonspecific such as chronic pericarditis, congestive heart failure, pericardial effusion, tamponade, conduction disturbances or defects, arrhythmias such as ventricular or supraventricular heart rhythm disturbances (23,24), syncope, embolism events such as transient ischemic attack and hemodynamic changes secondary to valve dysfunction.

Malignant melanoma has the highest rate of metastases to heart; however, due to improvement in treatment for this disease, longer survival than previous is now possible (25) and with newer imaging modalities early detection of metastases is possible and the physician should be alert of the risk of metastases. Transesophageal echocardiography has higher sensitivity than transthoracic echocardiography and cardiac magnetic resonance imaging with its ability to define the mediastinal involvement could also be used. According to tumor characteristics, its burden, location and size, palliative surgery or complete resection or adjuvant systemic therapy is recommended.
