3 DISCUSSION
Ebstine anomaly is essentially a tricuspid valve disorder which begins in the embryonic stage by failure of delamination 2, 5. Due to failure in delamination of inner layer of inlet part of right ventricle in EA we see adherence of septal and posterior leaflets to the underlying myocardium and as a consequence we saw downward displacement of hinge points of septal and posterior leaflets from atrioventricular junction 2, 5, 6. In contrast to septal and posterior leaflets, anterior leaflet usually remains in the normal position due to different embryonic origin of anterior leaflet versus posterior and septal leaflets 4, 7. Septal (medial) and posterior (inferior) leaflets originate from the tricuspid gully7 but the anterior leaflet developed from the lateral endocardial cushion and lateral conus 2, so that, anterior tricuspid leaflet is very rarely affected in EA and the attach point of the septal and inferior leaflets never apically displaced beyond the junction between ventricular inlet and apicotrabecular component of RV 1, 7 and the junctional hing of the anterior leaflet is very rarely affected 2, 7.
In our case which the symptoms represented in adulthood, a rare variant of EA was seen with downward displacement of all three tricuspid leaflets. Ebstein cases may represent at different ages due to severity of structural and functional abnormality and also presence of associated defects 8, such as our patient which well tolerated till 35 years old and passed tow pregnancies with no complain of dyspnea or right side failure symptoms. There was no same case in literature with apical disposition of all three tricuspid leaflets. There was reported few cases of isolated anterior leaflet displacement and not septal and posterior ones, and displacement of septal or posterior leaflets is the regular kind of EA, but apical downward of all three ones was not reported till now.