This 48-year-old woman with Trisomy 21 has a known large ventricular septal defect and EIsenmenger syndrome. She is on continuous oxygen therapy and is very limited by dyspnea and fatigue on mild exertion:  

• Sinus rhythm with one premature ventricular complex
• First degree AV block
• Biatrial enlargement
• Right bundle branch block
• Left anterior fascicular block
• Left ventricular hypertrophy

In patients with VSD and Eisenmenger syndrome there is usually right axis deviation, however some patients with an endocardial cushion defect may show left axis deviation and a pattern of left anterior fascicular block.