Clinical introduction A 23-year-old woman followed at another medical centre for congenital heart disease (CHD) presented to our emergency clinic with 3 weeks of bilateral pleuritic chest pain. She returned from holiday in Greece 6 weeks earlier where a tattoo and nasal piercing had been performed. There was no history of night sweats or fever.

Her temperature was 37.5°C, heart rate 120 beats/min, oxygen saturations 94% on room air and blood pressure 110/74. Her chest was clear and there was systolic murmur on auscultation. The chest radiograph showed peripheral bilateral lower zone atelectasis. The ECG demonstrated sinus tachycardia. The haemoglobin was 11.2 g/dL, white cell count 10.18×10⁹/L, C-reactive protein 67 mg/L (normal <5 mg/L) and D dimer=430 ng/mL (normal <230 ng/mL).

A pulmonary embolus was suspected and a CT pulmonary angiogram was performed (figure 1).

Question Based on the CT findings, what is the most likely underlying congenital heart lesion in this patient?

1. Bicuspid aortic valve

2. Coarctation of the aorta

3. Fontan circulation

4. Parachute mitral valve

5. Ventricular septal defect

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Figure 1

CT pulmonary angiogram (coronal views).