HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
45-year-old male. Native of Conakri, capital of Guinea, resident in Spain since May 2016. Diagnosed with untreated diabetes mellitus on admission; no personal or family history of heart disease, history of heart failure or sudden death. He consulted the emergency department of our centre due to progressive dyspnoea on exertion, until becoming minimal effort (walking less than 5 metres) in the last year. He reported stopping at least three times to climb a flight of stairs. He also presents palpitations, oedematisation of the lower limbs and increased abdominal perimeter. He reports orthopnoea and paroxysmal nocturnal dyspnoea. He denies angina on exertion. On physical examination, eupneic at rest, tolerating decubitus at 20o, well perfused.
Cardiac auscultation: rhythmic heart tones, tachycardic, with S3 and systolic murmur II/VI in tricuspid focus that increases with inspiration. Jugular ingurgitation. Pulmonary auscultation: light bibasal crackles. Distended abdomen with hepatomegaly of 3 tracts. Oedema in the lower limbs up to the thighs and in the abdominal wall.

COMPLEMENTARY TESTS
Electrocardiogram: sinus tachycardia at 102 bpm. QRS with axis at -60o. BRDHH and HBAIHH. QR pattern in right precordial leads suggestive of right ventricular growth and overload, with ST underleveling and negative T waves in the same. Poor R wave progression in precordial leads. V5-V6 notching with rsr ́s ́ complexes.
Electrocardiogram during admission: sinus rhythm at 78 bpm. Axis at -60o. BRDHH and HBAIHH. qR in right precordials with ST underleveling and negative T waves in the same. Notching in V5-V6.
CBC: Glucose 124 mg/dl. Creatinine 1.34 mg/dl. GOT 41 U/l. GPT 16 U/l. Sodium 138 mmol/l. Potassium 4.55 mmol/l. Haemoglobin 13.7 g/dl, platelets 205,000/μL. Leukocytes 5,670/μL. Slight iron deficiency (iron 34 μg/dl) with normal transferrin and ferritin. TSH 1.95 U/l. HbA1c 7.1%. Total cholesterol 167 mg/dl, LDLc 114 mg/dl, HDLc 34 mg/dl, triglycerides 95 mg/dl. Coagulation: INR 1.43, PTTA 29.5. Factor II 57 %. Factor V 66 %. Factor VII 40 %. Factor X 57 %.
Chest X-ray: cardiomegaly at the expense of right cavities. Signs of vascular redistribution and fluid in minor fissure.
Serology: Toxoplasma, Echinococcus, Trypanosoma, Treponema pallidum, Strongyloides stercoralis, Schistosoma negative. Peripheral blood parasitaemia negative. Plasmodium IgM negative and IgG 1:80 (recent infection). Trichinella, Fasciola, Taenia negative. HIV negative. HAV IgM negative with positive total Ac. HBV: HBcAc positive, antiHBe undetermined and AntiHBs positive.
Transthoracic echocardiogram: LV endomyocardial fibrosis. Severe LV systolic dysfunction with LVEF 20% and restrictive diastolic pattern. Low cardiac output. Dilated RV, hypocontractile with TAPSE of 11 mm, without clear image of apical occupation. Slight left atrial dilatation and moderate dilatation of the RA. Mild functional MR. Severe functional TR. Severe pulmonary hypertension. Slight right retroauricular pericardial effusion.
Angio-CT pulmonary arteries and cardiac CT: minimal focal repletion defect in the periphery of the posterior basal segmental branch and lateral subsegmental branch of the LID, compatible with chronic PTE. Cardiomegaly with signs of right HF. Atheromatosis in aortic arch and coronary arteries. Increased fat density in the middle mediastinum not individualising the oesophageal wall, non-specific.
Coronary angiography: coronary artery disease of 1 vessel. Anterior descending with critical ostial lesion, diffusely diseased vessel with borderline calibre and TIMI 2 distal flow. The apical portion is filled by homocoronary circulation from epicardial vessel coming from circumflex.

EVOLUTION
Admitted to the cardiology ward for heart failure on debut, predominantly right heart failure, CF III/IV NYHA; restrictive cardiomyopathy compatible with LV endomyocardial fibrosis, with severe LV systolic dysfunction and restrictive LV filling pattern associated with dilated and dysfunctional RV with severe TR and data of pulmonary hypertension was observed on echocardiography. Depletive treatment was started with good response and progressive titration of neurohormonal treatment (bisoprolol 2.5 mg/24 hours, ramipril 5 mg/24 hours, eplerenone 25 mg/24 hours). Angio-CT of the pulmonary arteries was requested with a diagnosis of chronic PTE and thoracic CT to assess the extent of endomyocardial fibrosis, with absence of endomyocardial calcification, showing coronary atheromatosis. Coronary angiography showed coronary artery disease of the anterior descending artery with critical ostial lesion, visualising a diffusely diseased vessel of borderline calibre. The patient was screened for infections as an aetiopathogenic factor of the endomyocardial fibrosis. Given the patient's characteristics, absence of angina, LV dysfunction secondary to endomyocardial fibrosis, ASA and statins were associated with the medical treatment already prescribed and the case was presented in a medical-surgical session (endomyocardial resection +/-CABG). The patient was rejected for surgery to resect masses and revascularise the LAD due to high surgical risk. Oral anticoagulation was not started due to a significant language barrier and high risk of non-compliance with treatment. During follow-up, the patient did not attend outpatient check-ups.

DIAGNOSIS
Debut heart failure related to restrictive cardiomyopathy due to LV endomyocardial fibrosis. Severe pulmonary hypertension. Chronic pulmonary thromboembolism. Severe functional tricuspid insufficiency.
Ischaemic heart disease. 1-vessel coronary artery disease, without clinical signs of angina. Type 2 diabetes mellitus.
