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A 76 year old woman was admitted to our cardiology clinic with a history of dyspnoea on exertion and palpitation over a period of several months. Irregular cardiac rhythm, augmented pulmonary component of second heart sound, and mild apical systolic murmur were detected at physical examination. Her blood pressure was 140/80 mm Hg with a pulse of 74 beats/minute. Iron deficiency anaemia was detected on blood test analyses. Electrocardiography showed atrial fibrillation with normal ventricular response. Chest x ray revealed an increased cardiothoracic index and a dome shaped air level within the heart silhouette (left). There was no evidence of ventricular dysfunction or pericardial effusion on transthoracic echocardiographic examination. A giant paraoesophageal hiatal hernia was detected on barium x ray of the oesophagus–stomach–duodenum (right). After undergoing laparoscopic surgery to repair the hernia, the patient's symptoms resolved.
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