Tetralogy of fallots with quadrivalvular stenosis: a rare coexistence.

To cite: Vijay SK, Tiwari B, Misra M, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204407 DESCRIPTION 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 twodimensional (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 cm (figure 1C; gradient 21/10). The continuous wave Doppler examination showed the presence of severe infundibular pulmonic stenosis (peak gradient 158 mm Hg; figure 2A), severe tricuspid stenosis (mean gradient 8 mm Hg; figure 2B and video 3) and severe aortic stenosis (peak velocity 4.1 m/s; figure 2C). The continuity equation showed an aortic valve area of 0.7 cm and the pressure half-time method (PHT) showed a tricuspid valve area of 0.9 cm (PHT 206 ms). Transoesophageal echocardiographic (TEE) exmination confirmed all findings and clearly showed a bifurcating jet of moderate aortic regurgitation which filled both the ventricles (figure 3A and video 4). 3D TEE provided an en face view of