Congenital heart disease in an asymptomatic 29-year-old woman

Dr. S. Boyd Eaton: This patient, a 29-year-old white woman, had been known to have an asymptomatic heart murmur since birth. At the ages of 16 years and 19 years, she had subacute bacterial endocarditis which required hospitalization. In recent years, the patient has complained of easy fatigability, some chest pain, and occasional ankle edema. She denies cyanosis, exertional dyspnea, or orthopnea. Physical examination revealed a slightly enlarged heart. A grade 5/6 pansystolic murmur was heard maximally at the lower left sternal border transmitted to the axilla and neck. Blood pressure was 128/78 mm Hg and pulse rate was 100 beats per minute with occasional premature beats. Electrocardiogram showed incomplete left frontal branch block and left ventricular hypertrophy. Discussion Dr. Laurence L. Robbins: Dr. Tomchik, what do you think about this case? Dr. Frederick S. Tomchik: The roentgenographic configuration of the heart is quite unusual (Fig 1). The apex is