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A 44 year old man, in complete remission after three chemotherapy courses and allogenic peripheral blood stem cell transplantation for acute lymphatic leukemia (ALL), was seen at the outpatient clinic because of chronic graft versus host disease. He was treated with corticosteroids and responded well initially. Because of continuing weight loss and an isolated increase in lactate dehydrogenase (LDH), a bone marrow biopsy was scheduled. On entering the main lobby he suffered in-hospital ventricular fibrillation and was successfully resuscitated. Electrocardiography showed a wide variety of arrhythmias (panel below), ranging from ventricular tachycardia to complete atrioventricular block with an escape rhythm originating from the posterior fascicle. On transoesophageal echocardiography multiple thickened areas in the intraventricular and intra-atrial septum were seen, partly overgrowing the anterior mitral leaflet. In addition, there were annular, less echodense lesions that correlated very well with localisation of a tumour with necrotic spots (arrows, upper right panel). Leukemic signs in the peripheral blood were absent, however the bone marrow biopsy confirmed a relapse of ALL. No further treatment options were available and the patient died the next day from ventricular fibrillation. At necropsy, several organs showed ALL involvement including extensive cardiac localisation (lower right panel). Microscopic leukemic cardiac involvement occurs in 30–37% of necropsy series and is usually associated with leukemic manifestation in the blood. Macroscopic involvement is very rare and generally clinically silent.