atrial septal defect (asd) These images are from a 25 year old female that presented to her doctor with worsening dyspnea on exertion and no history of coronary artery disease. An echocardiagram was performed that demonstrated moderate-to-severe right atrial and right ventricular dilatation with normal LV thickness and systolic function. It was thought to be at least moderate pulmonary hypertension by Doppler with peak RV systolic pressure of 56 mmHg. Some mild MR and PI and severe TR by color flow. They did not visualize any obvious ASD on that echocardiogram. So the patient was transferred to Duke for evaluation for primary pulmonary hypertension (PPH). At Duke a right and left heart cath was performed that showed a Qp/Qs = 3, no evidence of pulmonary hypertension, no CAD, a left to right shunt of 10.4 L/min, and the catheter was noted to pass extremely easily from the RA to the LA. So a cardiac MRI was ordered to rule out an ASD. Cines that demonstrate turbulent flow in the 4 chamber view through the ASD as welll as the severely enlarged right heart. The RVOT and right sided 2 chamber view further demonstrate the enlarged right heart as well the the TR. 4chamber phase contrast image shows the true extent of the flow through the ASD. The biatrial view demonstrates the flow crossing the interatrial septum. These 2 views are used to get the "en face" view of the ASD below. en face views of the ASD using phase contrast MRI demonstrate the size of the ASD as well as calculates the flow through the ASD. The angiogram demonstrates no evidence of anomalous pulmonary veins. By Cardiac MRI the Qp/Qs = 2.5 and the dimension of the ASD were 2.4 x 2.2 cm. Flow through the ASD was 5.5 l/min. Not all ASD's are this large (this is the biggest one I've seen). Most are much smaller (measuring 0.5 - 1.0 cm) and are cigar shaped.