If you hear a new worrisome heart murmur…

An 86-year-old woman presented to our emergency department for acute dyspnea without chest pain. She had taken amoxicillin/clavulanate 1 g/q12h for acute bronchitis. She underwent a left nephrectomy for cancer twenty years earlier. Blood pressure, heart rate, peripheral oxygen saturation, respiratory rate, and body temperature were 110/60 mmHg, 112 bpm, 90% with a non-rebreather mask (15 L/min), 25 breaths/min, and 36.5°C, respectively. Arterial blood gas documented pH 7.31, pCO₂ 29 mmHg, pO₂ 49 mmHg, SatO₂ 90%, HCO₃ 14.6 mEq/L, lactates 3.8 mmol/L. Chest examination revealed absent vesicular murmur in the basal regions, crackles in the upper ones, and a pansystolic murmur. A lung ultrasound showed a white lung pattern with a severe pleural effusion and non-collapsible inferior vena cava. Laboratory findings documented WBC 18,610/mm³ with CRP 84 mg/L (n.v.<10), AST 489 U/L (n.v. 11-34), ALT 296 U/L (n.v.<33), and troponin T 5191 ng/L (n.v.<20). ECG and echocardiography are reported in Figure 1 and Video 1, respectively.