Diagnosis of a mild case of ebstein's anomaly by intracardiac ECG and pressure recording

Ebstein's anomaly is a rare congenital heart disorder characterized by apical displacement of tricuspid valve. Clinical presentation depends on degree of tricuspid valve malformation, displacement, degree of tricuspid regurgitation and associated arrhythmia. Mild cases are often asymptomatic and diagnosis can be missed unless a high degree of suspicion is maintained. Mild cases can be diagnosed by Cardiac Magnetic Resonance (CMR) imaging or by simultaneous intracardiac ECG and pressure recording. Our case presented with recurrent episodes of palpitation and breathing difficulty. He was evaluated elsewhere, but the exact diagnosis was missed. Physical examination and chest X-ray was normal. ECG showed subtle notching in terminal QRS in lead II, III and aVf. Initial echocardiogram was reported normal. Later on with careful clinical evaluation, subtle ECG finding and detailed echocariography ebsteins anomaly was suspected. Diagnosis was confirmed by recording ventricular EGM with RA pressure tracing from atrialised ventricle. With proper education and reassurance, he is asymptomatic at 1 year follow-up.