An 84-year-old woman presented with worsening symptoms of heart failure over several weeks including dyspnea, fatigue, orthopnea, and paroxysmal nocturnal dyspnea. On examination, she had elevated jugular venous pressure, hepatojugular reflux, edema, and signs of venous insufficiency. Imaging showed cardiomegaly, pulmonary venous congestion, and a preserved left ventricular ejection fraction.