When Preoperative Echocardiography Reveals More Than Expected: an Incidental Diagnosis of Ebstein Anomaly

Abstract

Background: Ebstein anomaly is an uncommon congenital cardiac defect characterized by the abnormal apical displacement of the septal and posterior leaflets of the tricuspid valve, leading to atrialization of a portion of the right ventricle. The clinical spectrum is highly variable, ranging from severe cyanosis and heart failure in the neonatal period to mild or asymptomatic disease that may remain undiagnosed until adulthood. Although some patients remain clinically stable for years, incidental detection of Ebstein anomaly in adults is relatively uncommon.

Case Presentation: A middle-aged patient presented with a traumatic greater trochanteric fracture and was scheduled for orthopedic surgery. As part of routine preoperative evaluation, transthoracic echocardiography was requested. The study unexpectedly revealed marked apical displacement of the septal tricuspid leaflet, severe right atrial enlargement, atrialized right ventricle, and moderate-to-severe tricuspid regurgitation consistent with Ebstein anomaly. The patient denied previous cardiac symptoms, cyanosis, syncope, or documented arrhythmias. Electrocardiography demonstrated sinus rhythm without pre-excitation. Following multidisciplinary discussion, orthopedic management was modified and the patient was referred for congenital cardiology evaluation.

Conclusion: This case highlights the importance of comprehensive cardiovascular assessment before non-cardiac surgery and illustrates how congenital heart disease may remain undiagnosed until adulthood. Incidental recognition of Ebstein anomaly can significantly alter perioperative management and long-term follow-up.