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Pulmonary vascular obstructive disease (PVOD) is a feared complication of congenital heart disease (CHD) associated with increased pulmonary blood flow. It presumably develops as a protective response to prevent pulmonary overcirculation in these patients. However, with time the changes become irreversible and, in advanced stages, correction of the defect is rendered futile and potentially hazardous. In most low-income and middle-income countries, comprehensive paediatric heart care has only recently become available. Because of serious paucity of resources, health system dysfunctions and limited awareness, only a small minority of infants and children with CHD receive timely correction.1 In spite of substantial early attrition there is still a large population of older patients with uncorrected CHD. A significant proportion of these are patients with uncorrected large left to right shunts and increased pulmonary resistance with PVOD.2 Because the response of the pulmonary vasculature to high pulmonary blood flow is not uniform and does not occur in a predictable fashion, a spectrum of possibilities is often seen. Thus it is possible to encounter an adult with a large ventricular septal defect or patent arterial duct who may still be operable and would benefit from closure of the defect. It is also possible to see an infant with ventricular septal defect who may not be operable …
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