Diastolic murmur in a child with an atrial septal defect

Phonocardiogram obtained at the left lower sternal border in a 5-year-old child with a 12 mm diameter secundum ASD associated with right ventricular volume overload. There is a diastolic murmur consistent with "relative" tricuspid stenosis. Auscultation at the left upper sternal border in this patient revealed a wide fixed split S₂ (refer to separate UpToDate phonocardiogram of a systolic murmur and fixed split S₂ in a child with an atrial septal defect]).