A 42-year-old man was transferred to St. Mary's Hospital, Rochester, Minnesota, for evaluation of hemoptysis. He was born in Laos and immigrated to the United States at age 6 years. He had a history of mitral valve commissurotomy 25 years previously in the setting of rheumatic mitral stenosis (MS). He also had known esophageal varices from cirrhosis secondary to chronic hepatitis B. He had been in a normal state of health until 6 months before presentation, when he began experiencing increasing dyspnea on exertion.