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A 40-year-old man presented to our institute with progressive exertional dyspnoea for 1 year. Bicuspid aortic valve (BAV) with mild-to-moderate aortic regurgitation (AR) was diagnosed in his childhood by echocardiography, but he declined follow-up afterwards. Physical examination revealed a grade 3/6 ‘to-and-fro’ murmur at the third left intercostal space. Chest radiograph showed an extremely enlarged cardiac silhouette (figure 1A), and ECG displayed complete left bundle branch block with frequent premature ventricular contractions. Transthoracic echocardiography demonstrated an extremely enlarged LV with end diastolic volume of 472 mL and EF of 20% (see figure 1B, C and online supplementary video 1).
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