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A 52-year-old was referred by his general practitioner with new atrial fibrillation. The patient reported 6 weeks of mild dyspnoea which was non-limiting, New York Heart Association (NYHA) class II. He had no chest pain, syncope, fevers or palpitations. Background was notable for Bentall procedure with Dacron graft and Medtronic-Hall mechanical aortic valve replacement at age 20 for severe aortic regurgitation (AR), aortic root dilatation and left ventricular (LV) dilatation. Prior echocardiography images were not available but reports indicated ‘free’ AR, severely dilated LV and normal LV ejection fraction (LVEF). He had been lost to cardiology follow-up after discharge from cardiothoracic clinic and had no subsequent imaging. He had good adherence to warfarin with International Normalised Ratio (INR) consistently within therapeutic range. He also took levetiracetam for epilepsy, though he had been seizure-free for over 10 years.