A 28-year-old man with a history of childhood surgery for congenital heart disease presents following an episode of hemoptysis. He reports a mild decline in his exercise tolerance during the past month. He had surgery as a child to close “a hole” in his heart but has not seen a physician since that time.

On his physical exam, his blood pressure is 115/75 mm Hg and pulse is 66 beats per minute and regular. His O₂ saturation is 88% on room air. Neck veins are elevated to the angle of the jaw. Carotid pulses are normal. Lungs are clear to auscultation bilaterally. Cardiac exam reveals a normal S1 with a loud P2 component of the second heart sound and a 3/6 holosystolic murmur at the left lower sternal border that is nonradiating. Extremities are warm with no peripheral edema.

Echocardiography is performed to evaluate left ventricular (LV) systolic function (Videos 7-1 and 7-2 and Figs. 7-1, 7-2 and 7-3).