66-Year-Old Female with a History of Heart Failure

66-year-old female with a history of heart failure with preserved ejection fraction and paroxysmal atrial fibrillation, presented to the clinic for worsening lower extremity edema. She was subsequently admitted for acute decompensated heart failure.

On examination, the jugular venous pressure was estimated to be between 13-15 cm H2O. She was not tachypneic. Her lungs were clear to auscultation bilaterally. A harsh systolic murmur was appreciated at the right upper sternal border. 3+ pitting edema was noted bilaterally extending up to the hips.

Her electrocardiogram revealed a normal sinus rhythm with no ST-T wave changes. Chest x-ray was unchanged from prior history. On laboratory work-up, pro-BNP was 1232 pg/ml (Normal: 0-125 pg/ml). A transthoracic echocardiogram was obtained. (Video 1)

Video 1

What is the most likely etiology of the findings seen on transthoracic echocardiogram?

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