ANSWER 1: C. The transthoracic images are of fair quality due to the patient’s body habits. The first image shows a markedly enlarged right heart with right ventricular hypertrophy and the interatrial septum bulging to the right, consistent with both the patient’s pulmonary hypertension and elevated right atrial pressure. The second image shows opacification of the left ventricle with saline contrast, confirming a large right-to-left shunt. The opacification was almost immediate, but the exact site of the shunt was not visualized on this study.

ANSWER 2: B. A TEE to identify the anatomy and site of the shunt would be a very reasonable first step. If a secundum atrial defect, which is the most common ASD, is detected then the TEE would help assess if the patient would be a candidate for a septal occluder device. There is no indication for a left heart catheterization. A right heart catheterization with saturations may still be indicated to evaluate the physiology of the shunt and evaluate pulmonary vascular resistance but would not clarify if the patient would be a candidate for percutaneous closure of an ASD. Correction of the intracardiac defect may be indicated rather than medical treatment of the pulmonary hypertension.