Letter addressed to : Copy to : Dr. René DEBRA - 14 place de la Victoire - 63000 CLERMONT6FERRAND

Dear Associate, Your patient MR KISER Kenneth, 81-year-old, stayed shortly in our service for complaints of shortness of breath. His history includes an operation for malignant melanoma in the liver in November, 2008. Moreover, he has a double probe pacemaker installed 8 years ago. He was therefore hospitalized considering his shortness of breath for several days. With early suspicions of pulmonary embolism, an angio scanner was done which eliminated these thoughts. Clinically, there is no sign of right or left cardiac insufficiency. The ECG shows a right ventricular stimulation with P wave P retrogression. This mode of stimulation shows pacemaker wear imposing its quick replacement. On biological plan, the pro BNP is augmented to 3817. There is not sign of infection. After discussion with the patient and his son, they decide to replace the pacemaker in France before his departure to the UNITED STATES. I therefore undertook the replacement of the unit, a pacemaker model MEDTRONIC ADAPTS. A verification of the leads showed the were functioning well. I undertook final configuration of the pacemaker per standard procedure. The stitches are disolvable. The procedure was done taking all consideration of the patients blood thinners. I explained to MR KISER and his son that in case of any complication, he could re-contact me and I would see him immediately. Supplemental examination of the angio scanner data clearly shows a tissue mass to the right of the spinal column looking at T2 and T3 measuring in 37 X 30 mm which seems attached to the back arch of the third rib. To supplement these findings, it would be necessary to perform a scintigraphy in search of secondary metastatic locations on the skeleton. This exam can be done in the UNITED STATES after his return. Attached, find the results of the tomodensitometric exam which was done in emergency. I am at your full disposal to see MR KISER again if needed. Warmly, DOCTOR F. JEAN