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A man aged 78 years who had been diagnosed with end-stage hypertrophic cardiomyopathy presented with dyspnoea. He was admitted to our hospital with a diagnosis of acutely exacerbated chronic heart failure. The patient had previously undergone bioprosthetic mitral valve replacement for non-rheumatic mitral regurgitation and pacemaker implantation for atrial fibrillation, with a slow ventricular response. He had received anticoagulation therapy (warfarin). Chest radiography revealed cardiomegaly with a markedly enlarged left atrial appendage ( figure 1 A). CT revealed massive left atrial enlargement (maximum diameter, 20.6 cm) and right-sided pleural effusion ( figure 1 B). A transthoracic echocardiogram showed a severely enlarged left atrium and mild degree of transvalvular regurgitation. The bioprosthetic mitral valve stenosis was insignificant; the mean pressure gradient of...