This is a 38-years old man who presented for the first time with breathlessness. The echo showed a perimembranous ventricular septal defect (VSD) and pulmonary arterial hypertension (PH). The MRI shows the perimembranous VSD, the aorta subtending the RV & LV and infundibular hypertrophy with resultant RVoT obstruction. To find a tetralogy of Fallot morphology presenting for the first time at this age is highly unusual. #adulttcongenital #congenitalheartdisease #ToF #tetralogyoffallot