Jon-Emile S. Kenny MD [@heart_lung] “It's these expressions, I never give, That keep me searching for a heart of gold … And I'm gettin' old.” -Neil Young An 86 year old woman is admitted with progressive dyspnea and lower extremity edema. 8 months ago she received a trans-catheter aortic valve replacement (TAVR) for severe aortic stenosis, yet her symptoms did not abate. 2 months prior to presentation, a follow up transthoracic echocardiogram was performed which revealed a calculated right ventricular systolic pressure (RVSP) of 75 mmHg; she had tissue Doppler indices consistent with diastolic dysfunction and a normal ejection fraction. With this data, her outpatient cardiologist initiated her on sildenafil and slowly titrated her dose upwards. She had no other changes in her medications and she kept to her low sodium diet strictly; nevertheless, her symptoms accelerated and she was admitted with worsening pulmonary edema and a 5 kg weight gain.