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A 67-year-old man with a history of leftsided renal cell carcinoma (RCC) status after undergoing a radical nephrectomy presented to the oncology clinic after sustaining a pathologic fracture of the left humerus. Computed tomography revealed a right suprarenal mass with invasion into the inferior vena cava (IVC) and right atrium, confirmed to be poorly differentiated RCC on biopsy. Transthoracic echocardiogram (Figure 1) showed tumor thrombus occluding the IVC lumen; the tumor also extended into the right atrium, measuring 8 cm in circumference. Despite this direct invasion, cardiac function remained normal; there was no evidence of valvular or wall motion abnormalities, and left ventricular ejection fraction (LVEF) was preserved at 67%. Therapy for metastatic RCC was initiated with the tyrosine kinase inhibitor sunitinib at 50 mg daily. Body mass index (BMI) at this time was 24.8. Within 12 days of starting therapy, however, the patient exhibited symptoms of New York Heart Association class IV heart failure and was referred to the emergency department...

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