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A decision was made to proceed with surgical repair; however, the patient declined further intervention. Case 3 An asymptomatic 33-year-old female with a known small PM-VSD was followed up in our clinic. Past history was remarkable for a surgical closure of patent ductus arteriosus early in life. Physical examination was notable for a pansystolic murmur (grade II/VI) at the left sternal selleck chemical border. ECG was normal. TTE revealed a small (-3-4 mm) PM-VSD with left to right shunt and RV muscular septation causing no significant obstruction. CMR showed prominent RVOT muscle bundles causing no significant flow turbulence (Fig. 1C and ?and2C,2C, Supplementary movie 3). No action was taken due to the benign nature of DCRV in this patient. Case 4 An asymptomatic 17-year-old male, with a history of surgical closure of PM-VSD at age 12, presents for routine follow-up. Physical examination was notable for an ejection systolic murmur (grade II/VI) at the left sternal border. ECG was normal. TTE revealed a RV muscular binedaline septation without significant obstruction (peak gradient of find more cardiac defect. While there may be a genetic predisposition for abnormal muscle band formation that contributes to this anomaly, it has not been clearly elucidated.1),2) The majority of DCRV cases are diagnosed and repaired early in life, however, it infrequently manifests in adulthood, because of the nonspecific nature of symptoms leading to a delayed diagnosis.3) RVOT obstruction is progressive in adults, and patients may present with effort dyspnea. In affected individuals with a significant mid RV obstruction surgical intervention of DCRV is indicated. However long-term outcome is unclear.4) Various mechanisms of DCRV have been postulated. Superior displacement of the septal marginal trabecula (moderator band) has been proposed, particularly in association with a VSD, and flow turbulence in the RVOT.1) This flow turbulence may trigger abnormal hypertrophy of the moderator band leading to DCRV.