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+A 75–year–old female presented in the Emergency Department of Ilfov Clinical Hospital, Bucharest, Romania, with dyspnea, orthopnea, lower extremities swelling, palpitations.
+She had a 3 years history of atrial fibrillation diagnosed by her family doctor and one-year history of cardiac failure NYHA (New York Heart Association) class Ⅱ.
+Physical examination revealed an irregular pulse 80 beats/min, blood pressure of 100/60 mmHg, bi–basal crackles on chest auscultation, lower extremities swelling.
+Heart sounds examination revealed a IVth degree pansystolic murmur at the left border of the stern.
+The jugular veins were dilated.
+The patient complained of pain in the upper right abdominal region, enhanced by palpation.
+The liver margin was tender, round, of 6 cm below the costal rib, with a smooth liver surface.
+The spleen could not be felt.
+EKG: atrial fibrillation of 80/min, right bundle branch block, infero-lateral ischemia.
+Transabdominal ultrasound showed a homogenous, enlarged liver.
+The suprahepatic veins were dilated, as well as the inferior vena cava (30 mm, without respiratory variations).
+Transthoracic echocardiography revealed a dilated right atrium of 74,2 mm (Figure 1), dilated left atrium of 55,2 mm, dilated left ventricle of 64/72,3 mm, dilated right ventricle of 44,4 mm.
+Atrial septal defect ostium secundum type, of 6 cm (Figure 2), with left–to–right shunt.
+Severe tricuspid insufficiency with maximum gradient of 55,4 mm Hg.
+4th degree mitral insufficiency.
+Severe pulmonary hypertension of 75 mm Hg.
+The ejection fraction of 29%.
+Atrial fibrillation.
+Interventricular sept with paradoxical motion.
+Flattening of the interventricular septum (Figure 3).
+The diagnosis was IVth degree chronic heart failure NYHA.
+Atrial septal defect ostium secundum type with left–to–right shunt.
+Severe tricuspid insufficiency.
+4th degree mitral insufficiency.
+Severe pulmonary hypertension of 75 mm Hg.
+Chronic atrial fibrillation.
+Right bundle branch block.