A 74 year old man reported increasing shortness of breath, which had progressed over the previous 18 months. He had three pillow orthopnoea and increasing peripheral oedema. The history indicated episodic minute haemoptysis. These symptoms were accompanied by intermittent fast palpitations. His medical history was unremarkable except for childhood rheumatic fever. He denied weight loss and smoking.

Examination showed NYHA II functional status. He was in a hypervolaemic state with a venous pressure at 4 cm, bibasal crackles, and pitting oedema bilaterally to mid-shin. On cardiovascular examination he had a pulse radially of 88 beats per minute irregularly irregular, and a pronounced mid-diastolic murmur associated with an opening snap heard loudest at the apex.⇓