A 30-year-old woman presented with a history of palpitations for 15 years and dyspnoea on exertion for 6 years. Her symptomatic status had worsened from New York Heart Association (NYHA) class 2 to NYHA class 3 in the last 1 year. On clinical examination, she had evidence of congestive cardiac failure and rheumatic mitral valve disease. ECG showed right axis deviation, left ventricular hypertrophy and atrial fibrillation (AF) with controlled ventricular rate. Her chest x-ray (figure 1) showed cardiomegaly and a hump-like convexity at the left cardiac border suggestive of an enlarged left atrial appendage (LAA). Transthoracic echocardiogram revealed dilation of all …