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Late presentation of large left to right shunts is a major problem in developing countries and evaluating the operability is a challenge during preoperative evaluation. The factors that determine the development and progression of the pulmonary vascular disease are still largely unknown, though there is evidence to show that increased pulmonary flow is the main contributing factor. We have found cases of operability despite late presentation of ventricular septal defect (VSD). In some of these cases, the reason for operability may lie i
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