A 73-year-old man presents with a 6 months history of worsening exertional fatigue and dyspnea on exertion. More recently, he has developed paroxysmal nocturnal dyspnea and worsening pedal edema.

Upon physical examination, there is jugular venous distension to the angle of the jaw. Lungs are clear to auscultation. Cardiac exam reveals a diffuse point of maximum impulse in the fifth intercostal space. S1 is normal, and there is an increase in the P2 component of S2. There is a loud third heart sound and a 2/6 holosystolic murmur in the apex radiating to the axilla. Extremities reveal 3 + pedal edema.

An electrocardiogram (Fig. 69-1) and 2D echocardiogram (Figs. 69-2, 69-3, 69-4, 69-5 and 69-6 and Videos 69-1 to 69-3) are performed.