A 29 year old man, was referred complaining of mild exertional dyspnea, dizziness and chest pain during the last 3 years. These symptoms remained stable during this time. When he was 15 years old, he had meningitis complicated by a cerebral abscess; at that time, in another institution, a harsh cardiac murmur was heard at the left external border and an echocardiographic examination have shown a four millimeter VSD, right ventricular hypertrophy and increased pulmonary flow. The cerebral abscess was surgically drained and the patient, after recovery, remained asymptomatic for the following 11 y. In the current clinical evaluation, physical examination revealed no cyanosis, heart rate of 80 bpm, arterial blood pressure of 110 × 70 mmHg; apical impulse was normopositioned at the 50 intercostal space. Cardiac rhythm was regular and there was a harsh intense ejection murmur in the low external border.\nThe ECG showed: sinus rhythm, right axis deviation, right ventricular overload and a minor degree of right bundle branch block. Transthoracic echocardiography (Figure and Figure ) showed: a 17 mm perimembranous VSD associated to a slow velocity flow from left to right ventricle; aortic root was slightly deviated to the right. In addition, there was RV hypertrophy and a muscular septation inside this cavity causing obstruction with a peak gradient of 80 mmHg. There was no obstruction to flow in the right outflow tract and the site of the right obstruction was displaced proximally preserving the right ventricular infundibulum. The pulmonary valve was completely normal.\nBased solely on the echocardiographic findings, the patient was referred to surgery which confirmed anatomical and functional abnormalities. VSD was closed and the right anomalous muscle band (Figure ) was successfully removed. After the procedure, patient remains free of symptoms and medications.
A 34-year-old male was evaluated for palpitation. Past medical history is significant for small PM-VSD years earlier with no intervention required. Physical examination was notable for an ejection systolic murmur (grade II/VI) over the left sternal border. ECG was unremarkable. TTE showed a small (4 mm) PM-VSD with left to right shunt and RV muscular septation causing no significant obstruction. TEE was confirmatory (, ). CMR showed prominent RVOT muscle bundles causing no significant flow turbulence (, ). No action was taken due to the benign nature of DCRV in this patient.