of apparent cyanosis of lips and peripheral extremities. The baby was a full-term normal delivery from a multipara woman of 35 years. The child was very frail, and the hospital records showed a low birth weight of 2.0 kg. There was no history of the maternal risk factor of congenital heart disease (morbid obesity, diabetes, febrile illnesses, smoking, alcohol intake, teratogenic drug and radiation exposure). On examination the child was weighing 2.5 kg, was extremely irritable, having distinctive tachypnea, and deep central cyanosis. The vital signs were HR 145/min, SPO2 76 % at room air, RR 50/min and 70/40 mmHg. On cardiovascular examination, there was a grade 2/6 pansystolic murmur heard at the upper left sternal border with a normal second heart sound. The pulses were symmetric and palpable and there were no signs of CHF. Chest X-ray showed cardiomegaly with evidence of reduced pulmonary blood flow (Figure 1) ECG was having sinus tachycardia and left axis deviation with LVH (Figure 2).
Figure 1: X-ray chest PA: cardiomegaly, reduced pulmonary blood flow.
Figure 2: Twelve lead ECG: Left axis deviation, LVH.

Figure 5: Apical 5CH view Double outlet left ventricle, Aorta is anterior and Pulmonary Artery is posterior, dilated LV, normal sized RV, hypoplasia of main and branch pulmonary arteries.

Mosiac pattern in pulmonary arteries is suggestive of turbulence in blood flow across mild pulmonary valvular stenosis.

A subaortic conus was distinctly detected (Figure 6). Meanwhile, pulmonary arteries were confluent and there was the presence of a left aortic arch. Mitral and aortic valves were normal, however, the pulmonary valve was domed and there was a presence of mild pulmonary stenosis with hypoplasia of pulmonary valve annulus, main and branch pulmonary arteries (Aortic valve annulus (D) 9.9 mm, PV annulus (D) 3.6 mm, main pulmonary artery (D) 3.0 mm, left pulmonary artery (D) 2.5 mm, right pulmonary artery (D) 2.6 mm). On CW doppler, peak pulmonary velocity was 1.95 m/sec with a peak gradient of 15.2 mmHg (Figure7). No infundibular obstruction was identified.
Figure 6: LAX view Subaortic VSD (moderate), characteristic subaortic conus, dilated LV.

Furthermore, there was a notable presence of Large ASD (Figure 8) and a moderate-sized VSD (Figure 9).

ASD was ostium secundum type of size 7.3 mm, with the right to left shunt. VSD was a subaortic membranous defect of size 4.3 mm, with a left to right shunt (Figure 10).

Figure 10: LAX view VSD jet is visualised with a left to right shunt across moderate size VSD.

VSD jet is denoted by arrows.

The peak velocity of the VSD jet was 1.34m/sec and the peak gradient was 7 mmHg. The left ventricle was dilated and the right ventricle was normal. No right ventricular hypoplasia was evident. The biventricular systolic functions were normal with an LVEF of 61%.

and bilaterally absent conus associated with DOLV in their series of “Malpositions of the heart” [2]. It is obvious from these case reports that conus location does not follow a fixed pattern. Our case had a subaortic conus and subpulmonic conus was absent.

Another important case report [16]. revealed the absence of subpulmonic conus in two of their operated cases of DOLV by pulmonary root translocation for biventricular repair. The absence of subpulmonic conus causes a technically different procedure to be undertaken because it requires careful dissection of the deeply set pulmonary valve, from atrioventricular valve(s), with which it is in continuity. Otherwise, a traditional aortic valve replacement with pulmonary autograft could have been undertaken. This case report highlights the importance of conus location, and its bearing on the planning of surgical procedures, to be embarked upon.

Colour doppler echocardiography has substantially expanded the horizons for accurate non-invasive diagnosis of congenital cardiac defects including complex congenital heart disease [20]. Echocardiography not only provides additional information but also improves the overall specificity of two-dimensional (2-D) echocardiography.

Traditionally, DOLV has been difficult to diagnose precisely. Previously angiography was considered indispensable and the diagnosis was often concluded by the surgeon or pathologist [21]. Hence, DOLV may have been underdiagnosed. Today, cardiac MRI as an adjunct to echocardiography provides reliable and sophisticated diagnostic techniques. However, our country, belongs to a low-income group of nations and cardiac MRI facility is extremely limited moreover, adequate trained academic teaching faculty of cardiac MRI, particularly with the expertise of reading and reviewing paediatric cardiology cases, are lacking. Moreover, it is time-consuming and expensive, which are other important hindrances to the use of this advanced technology in our motherland. Our institution does not possess a cardiac MRI. The innovative technology of 4Dimensional XStrain Echocardiography utilizes LV border tracking, by fusing speckle tracking information obtained from standard apical 2CH, 3CH and 4CH views, and delivering a more complete picture of cardiac function. This advanced technology merges