Small muscular VSD in 89 y.o. male - unrecognized

An 89 y.o. male was admitted for .... An echo performed for a murmur revealed a tiny muscular VSD with doppler velocity calculating a gradient of 106 mm Hg. In retrospect the tiny, clinically insignificant VSD is visible in mid-septum on the CT scan. 

Echo

Apical 4 chamber color doppler shows the tenting of the mid-muscular interventricular septum and the brief shunt jet from right to left.

Continuous wave doppler on the right side of the septum shows a velocity consistent with a pressure gradient across the VSD of 106 mm HG.

Note the small notch in the mid-interventricular septum indicating the tiny VSD.