Her physical examination was remarkable for the presence of a laterally displaced point of maximum impulse with a forceful right ventricular heave and a continuous 2/6 murmur that was best heard at the left upper sternal border and infraclavicular area. She had significant cyanosis and clubbing of all four extremities. The patient's chest radiograph (Fig 1) revealed massive enlargement of the main, right, and left pulmonary arteries. A gated cardiac 64-slice, multidetector CT scan, with 0.75-mm slice thickness, confirmed a widely the presence of a patent PDA measuring 2.0 cm in the largest diameter (Fig 2, 3). The main, left, and right pulmonary arteries were markedly enlarged (6.38, 4.6, and 5.5 cm, respectively). The ascending aorta measured 3.37 cm, resulting in a pulmonary artery aorta ratio of 1.89. A coronary evaluation demonstrated severe left main coronary artery (LMCA) stenosis due to compression by the enlarged pulmonary artery.