A 46-year-old woman known to have cyanotic congenital heart disease, is severely disabled:

• Sinus Rhythm
• First degree AV block
• Right atrial enlargement
• Incomplete right bundle branch block (iRBBB)
• Left anterior fascicular block
• Possible right ventricular hypertrophy
• Voltage criteria for left ventricular hypertrophy 

Comments: The patient had a large ventricular septal defect complicated by the Eisenmenger syndrome. The echocardiogram demonstrated pulmonary hypertension (RV systolic pressure 84 mm Hg), right ventricular hypertrophy, tricuspid regurgitation with a large right atrium, a myxomatous mitral valve with mitral regurgitation and left ventricular hypertrophy.