Chief Complaint: A 49-year-old female presented with exercise intolerance and palpitations that have worsened over the past two years.

Past Medical History: Significant for tetralogy of Fallot (TOF) status/post repair at age 10; prior left Blalock-Taussig shunt at age 2
Physical FindingsAge: 49 Gender: Female Blood Pressure: 150/70 mm Hg Pulse: 75 bpm Head and Neck: Jugular venous pressure estimated at 10 mm Hg with a prominent V wave Chest and Lungs: Clear to auscultation bilaterally Cardiac Exam: Left parasternal heave; second heart sound was single; 3/6 holosystolic murmur at the left lower sternal border and a diastolic murmur 3/4 over the left upper sternal border Abdomen: Soft; no hepatosplenomegaly Extremities: Absent left radial pulse; no cyanosis or clubbing of the digits Additional Info: ECG revealed normal sinus rhythm with right bundle branch block. QRS duration: 140 ms

Options
A. Aortic insufficiency (AI) with a dilated aortic root.
B. Residual ventricular septal defect (VSD) with enlarged right ventricle (RV).
C. RV dysfunction due to severe pulmonary insufficiency and chronic volume overload of the RV.
D. Residual VSD with enlarged RV, and overriding aorta, and AI.