Case history

A young male patient presented with a history of indigestion-like retrosternal discomfort. He reported retrosternal tightness on exertion associated with occasional sweating, nausea and shortness of breath. He was otherwise fit and well and medication free. On examination, his pulse was regular at 60 bpm, and his blood pressure was 122/78 mm Hg. On auscultation, the second heart sound was loud.

A 12-lead ECG at rest showed sinus arrhythmia with a rate of about 75 bpm, inverted T waves in leads III, aVF and V2, poor R wave progression, and a wide QRS complex. A chest radiograph revealed left-sided cardiac displacement in the absence of any pulmonary abnormality (figure 1).

Echocardiogram windows were suboptimal. Apical windows gave images that were closer to the standard parasternal windows. A cardiac MRI scan confirmed …