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This is a twenty year old man who has been deeply cyanosed from birth. There are huge hilar pulmonary arteries yet the pulmonary artery bay is only marginally convex. This is the clue that the MPA is not in its expected position, and this is a case of transposition of the great arteries with severe pulmonary hypertension. Survival to this age is uncommon, but there are few other malformations that can give this plain film appearance in someone who has been deeply cyanosed from birth. Truncus arteriosus would be a good alternative on the film, but he would probably been only mildly cyanosed in early life.