This is an example of Ebstein's Anomaly as heard at the tricuspid area.
The first heart sound is increased due to thickening of the tricuspid valve leaflets.
The second heart sound is normal.
A rectangular murmur of tricuspid regurgitation fills all of systole.
An opening snap occurs 100 milliseconds into diastole followed by a decrescendo-crescendo murmur of mitral stenosis.
These findings are all a manifestation of downward displacement of the tricuspid valve into the right ventricle
In the anatomy tab you can see the enlarged right atrium and the small right ventricle. The upward plume from the right ventricle to the right atrium represents the systolic murmur.
The downward plume from the right atrium to the right ventricle represents the diastolic murmur.
This abnormality is congenital in nature.