HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
The patient is a 47-year-old woman from Romania, resident in Spain for 10 years. No known drug allergies. Ex-smoker and former injecting drug user, which she gave up completely in 2000. Currently married, runs her own handicraft workshop. In 2000, the patient had suffered an episode of infective endocarditis on the tricuspid valve, which was operated on in her native country by total valve explant. There was no subsequent follow-up for years. In 2014 the first contact with cardiology in our country took place: she consulted for progressive deterioration of functional class and was diagnosed with chronic heart failure. Control echocardiograms showed progressive dilatation and severe dysfunction of the right ventricle as well as severe displacement of the interventricular septum towards the left chambers, which limited left ventricular filling. Despite the optimisation of hygienic and pharmacological measures, over the years the clinical symptoms of heart failure progressed to a situation of severe functional limitation (NYHA III-IV/IV) with dyspnoea on slight exertion, as well as the need for admission for intravenous diuretic treatment. Along the way, she also developed atrial fibrillation, with difficulty in frequency control. For all these reasons, she was referred from her centre to our hospital for evaluation of advanced therapies for heart failure. She was treated with furosemide between 40 and 80 mg per day according to self-adjustment, aldactone 100 mg per day, acenocoumarol 23 mg per week and digoxin 1 tablet per day. On admission, the patient was haemodynamically stable, with a tendency to well tolerated arterial hypotension. She presented with frank right congestion and signs of low cardiac output, including postprandial abdominal pain and marked asthenia. In addition, although the patient had not presented syncope, she reported occasional episodes of dizziness with sweating, related to exertion, especially at times of increased decompensation of heart failure.
Vitals: BP 100/50 mmHg, HR 60 bpm, SatO2 97 % (without supplementary O2). On physical examination, central cyanosis. Jugular ingurgitation visible up to the earlobe with marked v-wave. Cardiac auscultation was arrhythmic, with a gallop in the right third tone, as well as a pansystolic murmur III/VI also audible from the back. Pulmonary auscultation with no significant findings. Abdomen with pulsatile hepatomegaly (visible without palpation), painful 5 finger traverses. There was no oedema in the lower limbs.

COMPLEMENTARY TESTS
ECG: atrial fibrillation with ventricular response at 100 bpm, right inferior axis with BRD and negative T wave from V1 to V6 and in inferior leads.
Chest X-ray: sternotomy suture. Voluminous global cardiomegaly with very significant enlargement of the right ventricle and left chambers. Accessory lobe and fissure of the azygos. No significant pleuropulmonary alterations.
Echocardiogram: left ventricle not dilated, with normal wall thickness. Very marked systolic and diastolic bulging of the interventricular septum towards the left ventricle, predominantly diastolic. Global systolic function slightly depressed. Normal transmitral filling pattern. Interatrial septum displaced towards the left atrium. Slightly dilated left atrium. Severely dilated right atrium and right ventricle. Dysfunctional RV, with absence of tricuspid valve, functionally acting together with the RA as a single cavity. Pulmonary valve with dilatation of the annulus with insufficiency that is difficult to assess in terms of severity. Morphologically normal mitral valve. Mild insufficiency. Sclerosed aortic valve, good opening and functionally normal. Pulmonary artery systolic pressure not estimable. Inferior vena cava severely dilated, plethoric, without collapse. Severely dilated suprahepatic veins. No pericardial effusion. Aortic root not dilated.

EVOLUTION
Given the semiology of right congestion, treatment was started with intravenous diuretic. The patient showed signs of low anterograde output, so he received inotropic support with dobutamine and subsequent weaning with levosimendan. Significant symptomatic improvement, although with significant difficulty in switching from depletive to oral treatment, requiring frequent appointments at the Cardiology day hospital, some of which required admission for treatment intensification. Given the evolution of the patient, it was decided to perform a pre-transplant study, for which there were no contraindications. The only incident was a personal history of hepatitis C virus (genotype 1a and high viral face) which had been treated with simeprevir and sofosbuvir, and was considered cured (prolonged sustained viral response for years) and secondary complications were ruled out by means of a complete digestive study. As a result, the patient is currently on the waiting list for elective heart transplantation.

DIAGNOSIS
Right heart failure in advanced functional class (IV/IV NYHA) secondary to tricuspid valvectomy as treatment for infective endocarditis. Severe dilatation and right ventricular dysfunction. Secondary mild left ventricular dysfunction. Permanent atrial fibrillation. Cured HCV infection. Inclusion on the elective list for heart transplantation.
