PMC10318994_01
Transthoracic echocardiogram findings. A-B. Anterior 4-chamber view (A4V) shows a GD in the membranous septum (white arrow), color Doppler shows left to right shunt and aliasing due to flow acceleration (white arrow), continuous Doppler shows velocities greater than 5 m/s. C-F. Parasternal short axis view (PSAV) in the aortic plane in systole (CD) and diastole (E-F) shows the GD (white arrows), subaortic membrane (arrowhead), tricuspid septal leaflet (asterisk). The color Doppler shows the shunt directed towards the base of the tricuspid septal leaflet, and the drop in flow velocity allows us to appreciate its course. G. Parasternal long axis view (PLA) in the aortic plane in systole shows the subaortic membrane (arrowhead).
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The Qp/Qs was 1.1, and we also found an image suggestive of a subaortic fibromuscular ring or membrane that did not produce left ventricular outflow tract obstruction (Figure 1).
Transesophageal echocardiogram findings. A-B. Mid-esophageal (ME) 50  view shows the GD (white arrow) that connects the left ventricle to the right atrium (RA). There is also on the outflow tract a subaortic membrane (arrowhead). And the color Doppler shows the aliasing produced by the high-speed LV-RA shunt (white arrow). C. Multiplanar and a 3D view show the GD that communicates LV-RA (white arrow). RV: Right ventricle; LA: Left atrium.
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Initially, the first diagnosis was a ruptured sinus of valsalva with right aorto-atrial fistula (AAF); however, the transesophageal echocardiogram (TEE-2D/3D) showed that the defect communicated the left ventricle and the right atrium; and confirmed the subaortic fibromuscular ring (Figure 2).