To the editor:In August 2013,a 72-year-old Caucasian female was admitted with history of recurrent bilateral pleural effusions and signs and symptoms suggestive of fight sided heart failure.This started three months back,after she underwent catheter ablation of atrioventricular node and pacemaker placement for permanent atrial fibrillation in an outside hospital.Her transthoracic echocardiogram showed mild systolic dysfunction,grade 3-4 diastolic dysfunction,moderate mitral regurgitation,and severe tricuspid regurgitation.