A 72-year-old man presented to the emergency department with a history suggestive of a transient ischemic attack. On physical examination, he had bilateral expiratory rhonchi and no residual neurological deficit. A chest radiograph, obtained on admission, did not reveal any obvious lung mass or nodule. As part of the evaluation protocol, a transesophageal echocardiogram (TEE) was performed to rule out a possible cardioembolic etiology. The TEE showed normal left ventricular systolic function,

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... ldly dilated right ventricle with moderately elevated right ventricular systolic pressure, and a patent foramen ovale with a right-to-left shunt ( Figure 1A ). With color Doppler interrogation, a highvelocity flow with aliasing was noted in the right upper pulmonary vein (RUPV) ( Figure 1B) . By continuous wave Doppler, the peak velocity was noted to be 227 cm/s with a mean gradient of 14 mm Hg ( Figure 1C ), indicating hemodynamically significant stenosis of RUPV. The Doppler waveform showed continuous forward flow in RUPV into the Figure 1. Representative TEE images showing a right-to-left shunt through the patent foramen ovale during saline contrast injection (A); a high-velocity flow with aliasing in RUPV by color Doppler (B); increased peak velocity and mean gradient and absence of flow reversal during atrial systole in RUPV by continuous wave Doppler (C); and normal waveforms in right lower (D), left lower (E), and left upper (F) PVs by pulsed Doppler interrogation. LA indicates left atrium; LLPV, left lower PV; LUPV, left upper PV; LV, left ventricle; RA, right atrium; RLPV, right lower PV; RUPV, right upper pulmonary vein; and RV, right ventricle.