Overview
The selected cyanotic example combines RV outflow obstruction with a large unrestrictive VSD: RV systolic pressure is near systemic, distal PA pressure and Qp are reduced, and right-to-left mixing lowers systemic oxygen saturation. Qp and Qs remain separate; the example does not assume Eisenmenger pulmonary vascular disease.
Its ECG illustrates RV hypertrophy and right-axis deviation, not obligatory post-repair RBBB. The murmur is the selected RV outflow sound; the unrestrictive VSD does not receive a separate high-gradient murmur. These are representative findings, not a diagnostic rule.
TOF already includes the VSD; choosing it exchanges the standalone Large VSD/Eisenmenger phenotype. Loading, rate and other selected conditions can change the bounded result. This is an unrepaired teaching anatomy, without surgical repair, collateral flow, pulmonary atresia or a dynamic tet-spell model.