Basic diagnosis is Down's syndrome. As a newborn this child had a total AVSD that could not be corrected because of abnormally attached papillary muscles. An obvious Eisenmengerþs cyanosis has developed, but without the symptoms of heart failure. First-degree systolic murmur is present and the second heart sound is enhanced. Two separate clicks can be seen on the phonogram, apparently originating from the tricuspid and mitral valves. The second heart sound is hardly split at all and the pulmonary component is very strong because of the elevated pulmonary circulation pressure. Echocardiography shows only a minor shunt in the valves between the atria and the ventricles which is why the spectrogram does not show clear shunt sounds. Age 19.0 years, height 145.0 cm, weight 53.0 kg. Area of auscultation: left fourth ic (LIC4).