CASE PRESENTATION
A thirty-year-old female with no significant medical history presented with dyspnea on exertion (NYHA class I). The physical examination revealed a blood pressure of 110/70 mm Hg with an irregular pulse rate of 76 beats/minute and had an oxygen saturation of 98% on room air. The neck veins were not distended. The lungs were clear to percussion and auscultation. The examination of the heart revealed a mid-diastolic as well as grade III pansystolic murmur at the apex. The abdominal examination yielded normal findings, and there was no peripheral edema. The electrocardiogram on admission showed atrial flutter with a variable block (Figure 1). The chest radiography revealed massive cardiomegaly with the left heart border showing a prominent main pulmonary artery and left atrial appendage. The right heart border showed a double contour of atrial shadow (Figure 2). An echocardiogram showed a giant left atrium measuring 14.4 cm x 16.7 cm that encroached on the other cardiac chambers with a left ventricular ejection fraction of 48% (Figure 3). Thickened mitral valves along with doming and restricted motion of anterior and posterior mitral leaflets were diagnostic of rheumatic heart disease (RHD). There was severe mitral stenosis with a mitral valve area of 0.9 cm2 on mitral valve planimetry and moderate MR with vena contracta of 4 mm and an effective regurgitant orifice area of 0.3 cm2. The patient was administered furosemide 20 mg PO daily with improvement and was discharged from the hospital. She reported continued improvement in her dyspnea on her follow-up visit in the outpatient clinic two weeks later.