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Woman in her 50s with shortness of breath on exertion
  1. Takao Konishi1,2,
  2. Hironori Murakami1,
  3. Shinya Tanaka2
  1. 1 Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
  2. 2 Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
  1. Correspondence to Dr Takao Konishi, Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Hokkaido 064-8622, Japan; takaokonishi0915{at}


Clinical introduction A 59-year-old woman visited an outpatient cardiology clinic due to shortness of breath on exertion. Physical examination showed no significant abnormality of vital signs. A III/VI systolic murmur was heard on the fourth intercostal space at the right sternal border. The majority of laboratory tests were normal. Chest X-ray showed a curved vessel shadow (figure 1A). Initial transthoracic echocardiography showed abnormal blood flow into the inferior vena cava (IVC) in the subxiphoid long axis view (figure 1B) and mild right heart dilatation (online supplementary figure 1). Transoesophageal echocardiography showed severe tricuspid regurgitation (online supplementary figure 2).

Figure 1

(A) Chest X-ray. (B) Colour Doppler image in the subxiphoid long axis view.

Supplementary data

Supplementary data

Question What is the most likely underlying disease for the patient’s shortness of breath on exertion?

  1. Pulmonary arteriovenous fistula.

  2. Pulmonary arterial hypertension.

  3. Lung cancer.

  4. Partial anomalous pulmonary venous connection.

  5. Isolated tricuspid regurgitation.


  • cardiac computer tomographic (ct) imaging
  • cardiac catheterization and angiography
  • congenital heart disease
  • pulmonary vascular disease

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  • Contributors TK drafted the manuscript and prepared the figures. HM and ST contributed to the conceptualisation of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The research committee at Hokkaido Cardiovascular Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.