BMJ Case Reports 2018; doi:10.1136/bcr-2018-225266
  • Images in…

Big heart

  1. Basma Hammad2
  1. 1 Department of Internal Medicine, Michigan State University, East Lansing, Michigan, USA
  2. 2 Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
  1. Correspondence to Dr Yehia Saleh, yehia.saleh{at}
  • Accepted 30 May 2018
  • Published 8 June 2018


A 66-year-old female patient with a history of persistent atrial fibrillation and severe mitral stenosis secondary to rheumatic heart disease for which she underwent mitral valve replacement 25 years ago presented with progression of her baseline dyspnoea. On presentation, she had stable vital signs; neck examination revealed bilateral congested neck veins with prominent systolic venous pulsations. Chest and heart auscultation revealed a well-heard mechanical click, a pansystolic murmur heard over the tricuspid area and diminished air entry over the right lung base.

ECG revealed atrial fibrillation. Laboratory work-up showed that she was adequately anticoagulated but otherwise unremarkable; chest X-ray showed significant cardiomegaly, tracheal shift to the right and obliteration of the right basal lung field (figure 1).

Figure 1

Chest X-ray showing significant cardiomegaly, tracheal shift to the right and obliteration of the right basal lung field.

Echocardiography showed a preserved systolic function, well-functioning mitral valve prosthesis, severe tricuspid regurgitation, severe pulmonary hypertension and …

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