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JAMA Clinical Challenge
August 12, 2020

Decreased Exercise Tolerance in a Young Woman

Author Affiliations
  • 1Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts
JAMA. 2020;324(10):995-996. doi:10.1001/jama.2020.8415

A 31-year-old woman presented to clinic with decreased exercise tolerance due to shortness of breath for the past 2 weeks. She has no chest pain but was experiencing heart palpitations a few times per week. She denies any significant medical history, takes only multivitamins, and mentions a childhood heart murmur that was never evaluated.

On examination, her blood pressure was 125/85 mm Hg, with a heart rate of 71/min and respiratory rate of 18/min. Physical examination revealed a fixed split S2 and a 2/6 systolic murmur at the left upper sternal border. An electrocardiogram demonstrated sinus rhythm with incomplete right bundle-branch block. A chest radiograph was obtained (Figure 1). Transthoracic echocardiography demonstrated an enlarged right atrium and right ventricle; results of contrast echocardiography were negative.

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    1 Comment for this article
    Beware Negative CMR
    Nick Hollings, MB BS | Royal Cornwall Hospital
    Thank you for this nicely discussed case. My only comment is that, depending on the sequences used, APVD/sinus venosus defects can be surprisingly difficult to identify on CMR, especially if not suggested by the history or examination findings. Sometimes, with its higher spatial and temporal resolution, cardiac CT (CCT) can be a more useful tool. Assuming normal body habitus, imaging at 80kV results in low dose scans (1-2mSv, corrected). Of course, CCT does not give information about shunt size etc.