Ricardo Álvarez-Santana, Institute of Biomedical Sciences, Autonomous University of Ciudad Juárez, Chihuahua, Ciudad Juárez, Department of Nuclear Cardiology. National Institute of Cardiology, Mexico City;¡, Mexico Jesus A. Garcia-Diaz, Department of Nuclear cardiology, National Institute of Cardiology Ignacio Chávez, Mexico City; 3Academic Unit of Medicine, Autonomous University of Nayarit, Tepic-Nayarit. Mexico Mara Escudero-Salamanca, Departamento de Cardiología Nuclear, Instituto Nacional de Cardiología “Ignacio Chávez”, Facultad Mexicana de Medicina Universidad La Salle, Ciudad de México, México Roberto Cano-Zarate, Department of Magnetic Resonance, National Institute of Cardiology Ignacio Chávez, Mexico City, Mexico Nilda Espinola-Zavaleta, Department of Nuclear Cardiology. Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico; Department of Echocardiography, ABC Medical Center I.A.P, Mexico City, Mexico

Female 23-year-old patient with heart murmur diagnosed in the first year of life. She attended to our institute with progressive dyspnea and palpitations of 7-month evolution. Physical examination showed perioral and distal cyanosis with digital clubbing, oxygensaturation of 79%, jugular plethora, arrhythmic heartsounds of upper limbs, fixed second heart sound, systolic tricuspid murmur, and edema. Electrocardiogramand 24 hour Holter monitoring showed atrial fibrillationand right bundle branch block.