One of the main symptoms of people with long-term respiratory conditions is perceived dyspnea or breathing trouble [1].  For many, this condition worsens steadily over time until it becomes incapacitating.  In addition to limiting activities, dyspnea is frequently linked to significant psychological comorbidity, social isolation, and a low perceived quality of life.  Modern therapeutic approaches that aim to change the underlying chronic illness are only partially effective, and managing dyspnea effectively continues to be a significant issue for caregivers.  For individuals with chronic pulmonary diseases, activity-related dyspnea is typically the first and most problematic symptom. Recent research has shed light on the nature and mechanisms of perceived respiratory discomfort by examining the connection between the sensory response (the intensity and quality of dyspnea) and the measured physiological stress during physical exertion (the dyspneogenic stimulus) [2].

Anxiety or cardiac arrhythmias are the most common causes of palpitations, which are sensations of a fast or irregular heartbeat.  The majority of arrhythmia patients do not report experiencing palpitations. Palpitations, however, can be brought on by any arrhythmia, such as sinus tachycardia, atrial fibrillation, premature ventricular contractions, or ventricular tachycardia.  If palpitations are accompanied by dizziness, syncope, or near-syncope, they should be regarded as perhaps more dangerous.  Palpitations can be brought on by nonarrhythmic cardiac conditions such mitral valve prolapse, pericarditis, and congestive heart failure as well as noncardiac conditions like hyperthyroidism, vasovagal syncope, and hypoglycemia. Additionally, prescription and over-the-counter medications, as well as stimulant substances, can cause palpitations.  Up to 16 percent of individuals have no known etiology for their palpitations.  When the patient's history, physical examination, and resting electrocardiogram (ECG) cannot identify the cause of palpitations, ambulatory ECG monitoring is typically recommended [3].

One of the pre-hospital emergency medicine teams' potentially fatal interventions is sudden unexpected cardiac arrest.  Four to five million deaths worldwide are attributed to sudden cardiac death (SCD), which is typically associated with coronary artery disease.  Cardiomyopathies and channelopathies are additional causes, however the doctor is not usually aware of them [4].

With this background, we present here a case report about a 25-year-old female presented to us in the outpatient department with complaints of progressive exertional dyspnea, palpitations, and occasional dizziness over the past year.

CASE PRESENTATION

 A 25-year-old female presented to us in the outpatient department with complaints of progressive exertional dyspnea, palpitations, and occasional dizziness over the past year. She had no significant past medical history, and her childhood development was unremarkable without any episodes of cyanosis, heart murmurs, or exercise intolerance. She worked as a school teacher and led an active lifestyle until her symptoms began affecting her daily activities.

Management

Initial management focused on symptomatic relief and optimizing hemodynamics:

• Diuretics: Administered to alleviate peripheral edema and reduce right atrial pressure.
• Beta-blockers: Prescribed to control palpitations and improve exercise tolerance.
• Counseling: The patient was educated about her condition and advised to avoid strenuous activities that could exacerbate symptoms.

Physical Examination Findings

On presentation, the patient was alert and oriented. Vital signs revealed a heart rate of 110 bpm, blood pressure of 110/70 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 92% on room air. On general examination there was 2+ pedal edema, but no cyanosis, clubbing, icterus, pallor or lymphadenopathy. The internal jugular veins were distended with prominent “a” waves. Cardiac auscultation revealed a widely split second heart sound and a holosystolic murmur best heard at the left lower sternal border. The rest of the systemic examination was unremarkable.

Laboratory Workup

Hemoglobin levels and thyroid function tests were normal. NT-proBNP levels were elevated, consistent with volume overload.

Echocardiography

An electrocardiogram (ECG) demonstrated sinus tachycardia, right atrial enlargement, and incomplete right bundle branch block. Chest X-ray showed significant cardiomegaly with a globular-shaped heart and decreased pulmonary vascular markings. Echocardiography revealed apical displacement of the septal tricuspid leaflet (>20 mm/m2 indexed to body surface area), severe tricuspid regurgitation, and atrialization of the right ventricle. The functional right ventricle was significantly reduced in size but exhibited preserved contractility.

Figure 1 showing Chest X-ray showed significant cardiomegaly with a globular-shaped heart and decreased pulmonary vascular markings and Figure 2 showing demonstrated sinus tachycardia, right atrial enlargement, and incomplete right bundle branch block.

Figure 1: Chest X-ray showed significant cardiomegaly with a globular-shaped heart and decreased pulmonary vascular markings

Figure 2: demonstrated sinus tachycardia, right atrial enlargement, and incomplete right bundle branch block

Final Diagnosis

Based on clinical findings and imaging studies, a diagnosis of Ebstein’s anomaly was confirmed. The patient’s condition was classified as Carpentier Type C (markedly atrialized right ventricle with severely restricted leaflet mobility).

Surgical Technique

Given her persistent symptoms and significant tricuspid regurgitation, the patient was referred for surgical evaluation. After multidisciplinary discussions, she underwent a cone reconstruction procedure, a surgical technique designed to restore tricuspid valve competence and optimize right ventricular function. The surgery was successful, with intraoperative findings confirming severe tricuspid valve deformity and extensive atrialization of the right ventricle.

Post-Operative Course

The patient’s recovery was uneventful. Post-operative echocardiography demonstrated minimal residual tricuspid regurgitation, improved right ventricular function, and resolution of right atrial enlargement. She was discharged on post-operative day 7 with instructions for gradual resumption of physical activity and regular follow-up visits.

Follow-up Study

At the 6-month follow-up, the patient reported significant improvement in her quality of life and functional capacity, achieving a NYHA Class I status. Repeat echocardiography confirmed durable surgical results with no progression of regurgitation or ventricular dysfunction.

CLINICAL DISCUSSION

We report the case of a 25-year-old female presented to us in the outpatient department with complaints of progressive exertional dyspnea, palpitations, and occasional dizziness over the past year.

Generally speaking, writers that conduct regular closure have not been very concerned with the surgical strategy to approach the ASD in Ebstein's abnormality.

Although the natural course of Ebstein's anomaly is a relentless progression to congestive heart failure, arrhythmias, or both in the majority of patients not undergoing operations, the indications for surgical intervention in asymptomatic patients remain controversial [5, 6].  These late-stage consequences have a high mortality rate [7, 8].  Additionally, it appears to be the case that late-stage surgical intervention has a lower likelihood of totally reversing the disease's destructive effects.

Sudden dyspnea at awakening may indicate a number of underlying illnesses or ailments.  In our case study, the patient had no symptoms or prior diagnosis of heart failure, despite the fact that congestive heart failure is one of the more common causes of nocturnal dyspnea.

Up to 25% of patients evaluated in an ambulatory setting have dyspnea, or shortness of breath, which is a frequent complaint.  Numerous underlying illnesses can cause it, some of which can be life-threatening and manifest rapidly (e.g., acute myocardial infarction, pulmonary embolism). Therefore, prompt assessment and focused diagnostic research are crucial.  Given that the term "dyspnea" encompasses a wide range of subjective feelings, overlapping clinical presentations and concomitant conditions, such as congestive heart failure and chronic obstructive pulmonary disease (COPD), can make diagnosing dyspnea a clinical problem.  This symptom's existence already indicates a higher risk of death [9].

CONCLUSIONS

This surgical technique for Ebstein’s anomaly was performed with significantly. The surgery was successful, with intraoperative findings confirming severe tricuspid valve deformity and extensive atrialization of the right ventricle. Early echocardiograms showed significant reduction of tricuspid insufficiency, and the follow-up showed improvement in a 25-year-old female patient clinical status and low incidence of reoperation.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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