Tetralogy of fallots with quadrivalvular stenosis: a rare coexistence.

A 30-year-old woman presented to us with a history of effort dyspnoea, palpitations and recurrent syncope. Her physical examination showed central cyanosis with clubbing of fingers and precordial auscultation revealed an ejection systolic murmur present in the left and right second intercostal spaces with the presence of middiastolic murmur at the apex and left parasternal area. The chest X-ray posteroanterior view revealed cardiomegaly with increased vacular marking (figure 1A). The two-dimensional (2D) transthoracic echocardiogram parasternal long axis view showed large perimembranous ventricular septal defect (VSD) and overriding of aorta with thickened and calcified aortic leaflets (figure 1B and video 1). Colour Doppler examination showed bidirectional flow across VSD, moderate mitral regurgitation (video 2) and moderate aortic regurgitation. The calculated mitral valve area by planimetry was 1.0 cm2 (figure 1C; gradient 21/10). The continuous wave …