A 76-year-old man with a history of renal cell carcinoma was referred for evaluation of chest pain and progressive dyspnoea on exertion. Physical examination showed distended neck veins up to 10 cm above the sternal angle with large V waves and on auscultation a loud 3/6 systolic murmur was heard along the left parasternal border radiating toward the right side of the upper sternum. The patient was evaluated by spiral computed tomography (CT) to rule out the presence of pulmonary embolus. A right retrocrural metastatic adenopathy was observed but there was no evidence of pulmonary emboli. …