Images of Memorable Cases: Case 147 This is the heart of a 38-year-old, previously healthy, asymptomatic woman who suddenly collapsed and died while watching TV. 147. Metastatic melanoma Autopsy of this patient disclosed extensive metastases not only to her heart, but also to her liver and intestines (image below). The site of the primary melanoma was never established. Death undoubtedly resulted from an arrhythmia. Cardiac metastases ordinarily are clinically silent. But when signs or symptoms do occur, pericardial effusion (with or without tamponade) and dysrhythmias are the most common presentations. Cardiac failure, however, as well as superior vena caval syndrome and other manifestations related to intracavitary metastases, may develop as well. From a percentage standpoint, melanoma is the most frequent neoplasm metastasizing to the heart (about 65%). Furthermore, the absolute amount of tumor deposited in the heart in cases of melanoma is far greater than that of any other cancer. In one reported case, for example, the melanoma-infiltrated heart weighed 2450 gm! Findings of this sort have given rise to the term “charcoal heart.”