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A 15 year old girl was referred to our heart failure and transplant clinic with hypertrophic cardiomyopathy. Physical examination revealed signs of right heart failure; echocardiography showed severe concentric hypertrophy of both ventricles in addition to reduced left ventricular systolic function, and moderate dilation of the left atrium and severe dilation of the right atrium. In addition to dilatation, the subcostal view in particular suggested pronounced right atrial hypertrophy. The resting ECG revealed giant P waves in excess of 1.5 mV, amplitude exceeding that of the QRS complex in many leads (right panel). The patient later underwent orthotopic heart transplantation.