Uncorrected adult tetralogy of Fallot is rare. 

This patient had periods of high oxygen demand in the emergency requirement and was noted to have polycythemia as well as a heart murmur. 

Pink Tetralogy of Fallot occurs because the degree of right ventricular outflow obstruction is minimal and does not result in a right to left shunt (therefore acyanotic). 

The chronic hypoxia causes the acquired / secondary polycythemia.

The patient underwent an outpatient correctional procedure for the cardiac anomaly including a pulmonary valve replacement, patch augmentation of the main pulmonary artery and right ventricular outflow tract.

Case with thanks to Corey Thompson.