This 36-year-old man with chronic renal failure treated with hemodialysis is followed in the cardiac clinic because of a bicuspid aortic valve with stenosis and regurgitation. One year ago, he was treated for a pulmonary embolism:

• Sinus rhythm, 78/min.
• Biatrial enlargement
• Left axis deviation – Left anterior fascicular block
• Left ventricular hypertrophy with repolarization abnormality

A recent echocardiogram showed a dilated hypertrophied left ventricle and a bicuspid aortic valve with valve area of 0.9 cm² and moderately severe regurgitation. The right ventricular systolic pressure was elevated to 83 mmHg, and both atria were dilated.