Case 165


A 54-year-old female patient with history of hypertension and dyspnea NYHA class II. In the past ten days, the dyspnea has worsened (NYHA class IV), along with two fainting episodes. Has been admitted to the ER somnolent, BP=70x50mmHg, palpable radial and DP pulses, pitting edema on lower limbs, left deviated ictus and liver palpable at 3cm of the costal verge. EKG with sinus rhythm, 90bpm, and a right branch conduction deficit. Transthoracic echocardiogram showed a severe tricuspid insufficiency, dilated and hypokinetic RV, PAP=128mmHg. A contrast enhanced computed tomography of the chest was made.

Based on the clinical picture and the attached image, which one the following diagnosis is the most likely?

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