A 63 year old man was referred to the outpatient cardiology laboratory for dobutamine echocardiography because of atypical chest pain. The transthoracic echocardiography had poor imaging quality but showed turbulent colour flow above the right atrium in the four chamber view. To define this further transoesophageal echocardiography (TEE) was performed (top). Where the inferior vena cava is normally seen, a large echodense mass (T) was seen protruding into the right atrium (RA). Colour flow of the same frame (bottom) shows turbulent flow (TL) of the inferior vena cava caused by a tumour obstructing the inferior vena cava–right atrium junction. The interatrial septum (IAS) is seen bulging towards the left atrium owing to high pressure in the right atrium cause by the obstructing mass. (LA, left atrium; SVC, superior vena cava.)

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Further investigations with computed tomography and magnetic resonance imaging revealed a large renal mass invading the inferior vena cava and extending in to the right atrium. Biopsy results were consistent with clear cell carcinoma of the kidney. The patient opted for palliative therapy.