Gross cardiomegaly on Chest X-ray PA view, with gross right atrial enlargement evidenced by the shift of the right border very much into the right hemithorax. Main pulmonary artery and right pulmonary artery shadows are also prominent. Clinically and echocardiographically there was severe mitral and tricuspid regurgitation and pulmonary hypertension. Though similar enlargement of the cardiac silhouette could be noted in a large pericardial effusion, the bulges along the contour are not seen in massive pericardial effusion. Elevated left bronchial shadow and a filling of the appendage region on the left border indicate associated left atrial enlargement.