Fig. 17. Transesophageal echocardiography revealed a large mass attached to the posterior mitral valve leaflet. Histological examination revealed that it was a melanoma, arising from an extracardiac primary. (Please see companion DVD for corresponding video.)

Fig. 18. Apical four-chamber (A4C) view showing compression of the right heart chambers from a large pleural mesothelioma. (Please see companion DVD for corresponding video.)

pericardial or myocardial invasion (please see companion DVD for corresponding video).

Metastatic spread frequently occurs by either direct extension to the pericardium, or via lymphangitic or hematogenous spread. Renal cell carcinoma, Wilms' tumor, and hepatocellular carcinoma can invade the right atrium by encroaching up the IVC, and bron-chogenic neoplasms can enter the left atrium via the pulmonary veins. The involvement of pericardium or invasion of the tumor from either the cardiac free walls (as opposed to septum) or contiguous great vessels may be a clue to the secondary nature of these tumors. Clinical symptoms from secondary metastases are often the result of associated pericardial effusion and, less frequently, to embolization or mass effect on the myocardium (see next section).

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