Background
Female, 51 years old.
Arterial hypertension. Chronic glaucoma.
No known allergies. No toxic habits.
On treatment with telmisartan 80 mg/day.
Baseline situation: active. Independent for activities of daily living. Dyspnoea on moderate exertion (NHYA II).

Current illness
She visits her family doctor for moderate dyspnoea of about 3 months of evolution. Since then she has also presented oedema in the lower limbs. She reported no previous history of chest pain or palpitations. A chest X-ray was performed and in view of the presence of cardiomegaly, preferential assessment in the outpatient cardiology department was requested.

Physical examination
BP: 130/90 mmHg
HR: 77 bpm
SatO2: 98%
Head and neck normal. No IY
CA: rhythmic, holosystolic murmur II/VI with R2 splitting
AP: VCM in both lung fields
Abdomen: nondescript
LES: oedema with perimalleolar fovea

COMPLEMENTARY TESTS
ECG: sinus rhythm at 75 bpm with signs of AD growth, normal PR, wide QRS (150 msec) with morphology of complete right bundle branch block and secondary repolarisation alterations. Echocardiography: severe dilatation of right chambers. Apical displacement of the insertion point of the tricuspid septal leaflet (about 2.5 cm with respect to the plane of the mitral annulus). Massive TR due to lack of leaflet coaptation. Assessment of RV systolic function is difficult but appears to be severely depressed. The pulmonary trunk is of normal size. The pulmonary valve has no abnormalities. The left chambers are small in size and displaced by the right chambers. LV systolic function is visually at the lower limit of normal. The left valves are normal. Mitral filling pattern of impaired relaxation. No ASD (although assessment is difficult), no other shunts. Normal aortic arch. Slight systemic venous congestion.

EVOLUTION
Furosemide 40 mg/day was added to the treatment, and cardiac magnetic resonance was requested for anatomical characterisation and better assessment of RV function. At the 6-month check-up, the patient was asymptomatic. The result of the cardiac MRI was brought in: a study of very poor technical quality (movement artefacts). Dilatation of the right chambers, with apical displacement of the tricuspid leaflets, which do not coapt. Free tricuspid regurgitation. RVEF 43%. No associated malformations are seen. Left ventricle displaced by the right, with preserved ventricular function. Given the improvement in symptoms, it was decided to maintain medical treatment and outpatient monitoring at 6 months with new echocardiography, new MRI and cardiopulmonary stress test.

DIAGNOSIS
Mild heart failure on debut
Ebstein's anomaly
Severe tricuspid regurgitation and mild RV systolic dysfunction
