Ventricular Tachycardia Due to Intracardiac Metastases: Multimodality Imaging and Management Considerations.

backgroundIntracardiac metastases are rare and often clinically silent but may present with malignant ventricular arrhythmias. Early recognition relies on multimodality imaging to establish diagnosis, guide management, and inform prognosis. CASE SUMMARY: A 57-year-old man with advanced metastatic renal cell carcinoma presented with syncope and subsequently developed hemodynamically unstable monomorphic ventricular tachycardia. Transthoracic echocardiography demonstrated apparent apical left ventricular hypertrophy with preserved systolic function. Contrast-enhanced perfusion echocardiography revealed heterogeneous early hyperenhancement consistent with tumor neovascularization. Cardiac magnetic resonance confirmed multiple poorly circumscribed, contrast-enhancing intramyocardial masses within the left ventricle, consistent with intracardiac metastases. Ventricular tachycardia morphology suggested an apical left ventricular origin, correlating with imaging findings. The patient was managed with antiarrhythmic therapy and later died from progressive disease. DISCUSSION: This case highlights the value of contrast perfusion echocardiography and cardiac magnetic resonance in diagnosing intracardiac metastases and elucidating arrhythmic mechanisms. TAKE-HOME MESSAGES: Multimodality cardiac imaging is central to establishing the diagnosis of intracardiac metastasis. Contrast perfusion echocardiography with "flash" high-mechanical index ultrasound beam is a cost-efficient alternative method to identify tumor with neovascularization.