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An 83-year-old woman with long-standing atrial fibrillation who had previously undergone atrioventricular nodal ablation and pacemaker placement presented with symptoms of progressive heart failure. Physical examination was notable for elevated jugular venous pressure, precordial lift, a grade 2/6 holosystolic murmur at the sternal border and apex, hepatomegaly, ascites, and severe lower-extremity edema. Laboratory evaluation revealed a creatinine level of 1.4 mg per deciliter (124 µmol per liter), an albumin level of 3.6 g per deciliter, and a brain natriuretic peptide level of 526 pg per milliliter (normal range, 0 to 100 pg per milliliter); liver function was normal. Chest radiography (Panel A) revealed cardiomegaly (cardiothoracic ratio, 0.86), splaying of the carina, and an elevated left main bronchus (arrows). An echocardiogram showed massive biatrial enlargement (left larger than right), normal ventricular size and function, and moderate mitral and tricuspid regurgitation (Panel B; LA denotes left atrium, LV left ventricle, RA right atrium, and RV right ventricle). An esophagogram (Panel C) obtained to evaluate dysphagia for solid food revealed a prominent impression of the left atrium on the esophagus (E), without evidence of obstruction. The patient was discharged home on medical management after prolonged diuresis.
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