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(A) A phonocardiogram recorded at the 4th left interspace shows that the pansystolic murmur of the VSD was absent. S1, the first heart sound; S2, the second heart sound. (B) Parasternal long-axis view of the transthoracic echocardiogram. A white arrow indicates the defect. A green arrow indicates hypertrophic right ventricular wall. RV, right ventricle; LV, left ventricle; AO, ascending aorta; LA, left atrium. (C): Pulse Doppler recording at the defect showing early systolic left-to-right shunt (white arrows) and mid-systolic right-to-left dominant bidirectional flow (yellow arrows) with the flow velocity of 1.0-1.4 m/s, indicating no pressure gradient.
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Notably, no typical pansystolic murmur was observed (Figure 1A). Echocardiography revealed a large, non-restrictive peri-membranous VSD with marked right ventricular (RV) hypertrophy (Figure 1B). Pulse-wave Doppler revealed a bidirectional shunt across the defect (Figure 1C).
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