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Endgames Picture quiz

Progressive shortness of breath

BMJ 2009; 338 doi: (Published 15 January 2009) Cite this as: BMJ 2009;338:a3095
  1. K Guha, specialist trainee year 2 ,
  2. S Piper, specialist trainee year 2,
  3. P D Collins, professor of clinical cardiology, National Heart and Lung Institute
  1. 1Department of Cardiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Trust, London SW3 6NP
  1. Correspondence to: K Guha kguha{at}

    A 74 year old man reported increasing shortness of breath, which had progressed over the previous 18 months. He had three pillow orthopnoea and increasing peripheral oedema. The history indicated episodic minute haemoptysis. These symptoms were accompanied by intermittent fast palpitations. His medical history was unremarkable except for childhood rheumatic fever. He denied weight loss and smoking.

    Examination showed NYHA II functional status. He was in a hypervolaemic state with a venous pressure at 4 cm, bibasal crackles, and pitting oedema bilaterally to mid-shin. On cardiovascular examination he had a pulse radially of 88 beats per minute irregularly irregular, and a pronounced mid-diastolic murmur associated with an opening snap heard loudest at the apex.


    • 1. What is the imaging technique and what views are shown?

    • 2. What is the diagnosis?

    • 3. What is the most likely cause?


    Short answers

    • 1 Transthoracic echocardiogram; parasternal long axis view (left) and four chamber view (right).

    Transthoracic echocardiogram, with colour Doppler (right). Ao=aorta, LA=left atrium, LV=left ventricle, MV=mitral valve, RA=right atrium, RV=right ventricle; arrow shows classic doming of mitral valve leaflet

    • 2 Mitral stenosis.

    • 3 Rheumatic fever with subsequent rheumatic heart disease.


    Rheumatic fever, and subsequent rheumatic heart disease, was once the most common cause of mitral valve disease in both the West and worldwide. Due to the increasing availability and use of antibiotics, together with improved housing and social conditions, the incidence of rheumatic heart disease has steadily declined in Western populations, with an …

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