SUMMARY We report 21 patients with discrete subaortic stenosis (DSS) causing mild obstruction with a peak systolic left ventricular outflow pressure gradients less than 50 mm Hg. They were followed 1-17 years (mean 6.5 years), and eight were recatheterized before surgery, 2-17 years after the first cardiac catheterization.Three patients (14%) had subacute bacterial endocarditis. Ten (48%) had aortic insufficiency, one of whom had no pressure gradient across the left ventricular outflow tract. In three of the 10 patients, aortic insufficiency was found only at the second catheterization. Nine patients (43%) had hyperactive, asymmetric left ventricular contraction; in three, this finding was present only at the second catheterization. Seven of the eight patients who were recatheterized (33% of the entire group) showed an increase in gradient. The increase was from a mean gradient of 35.2 mm Hg to 76.7 mm Hg. Seventeen patients (81 %) had at least one of these four features.In view of these data, we suggest that surgical indications for DSS might be expanded, although definitive recommendations are not possible. All cases of DSS should be carefully followed. Surgery should be performed if signs of progressive complications develop.DISCRETE subaortic stenosis (DSS) is an uncommon congenital cardiac lesion in which the left ventricular outflow tract is narrowed by a fibrous ring, a muscular ridge or a fibromuscular tunnel, either singly or in various combinations.' It is hazardous not only because of obstruction and hemodynamic impairment, but also because of its complications'-'": subacute bacterial endocarditis, aortic insufficiency, and possible development of an inherently associated muscular obstruction.DSS has been studied by many investigators.'-19 Most series, however, include mainly cases with moderate-to-severe obstruction, as these are naturally more likely to be studied. We report our experience with 21 patients with DSS and mild obstruction causing a peak systolic left ventricular outflow pressure gradient of less than 50 mm Hg or no gradient at all. Between 1963 and1980, 80 patients with DSS were studied. In all patients, the diagnosis was established by cardiac catheterization and angiocardiography, and in 56 who were operated upon, also by direct observation at surgery. Only patients with resting systolic pressure gradients across the obstruction of 50 mm Hg or less at first catheterization (measured by pullback of the catheter from the left ventricle to the aorta) were included in this study. Materials and Methods

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SUMMARYIn the 12 years from 1975 to 1987, 55 patients had open pulmonary valve surgery for isolated congenital stenosis of the pulmonary valve. Three types of pulmonary stenosis were seen: (a) dome-shaped pulmonary stenosis (34 patients); (b) dysplastic pulmonary valves with thick cauliflower-like cusps (12 patients), and (c) hour-glass deformity of the pulmonary valve, with "bottle-shaped" sinuses (nine patients). This third type has not been described before.Preoperative identification of the valve structure is important because the choice of treatment (balloon dilatation for some dome-shaped valves and excision for dysplastic and hour-glass valves) depends on the type of stenosis.Isolated pulmonary valve stenosis is the most common cause of right ventricular outflow tract obstruction and accounts for 8-10% of all congenital cardiac anomalies.' It was first described by Morgagni in 1761, and Meckel reported anatomical features in 1817.2In the most common form of stenosis, the pulmonary valve is conical as a result of fusion of the valve leaflets, and it protrudes superiorly into the pulmonary artery. Its shape and opening are influenced by the degree of thickness and rigidity of the fused cusps. Its appearance on angiography has led to the descriptive term dome-shaped pulmonary stenosis. The pulmonary valve was examined during operation; the structural characteristics were noted, including thickness and type of the cusps, degree of commissural fusion, form of the valve sinus, and the effective size of the valve orifice.

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Criss-cross heart is a recently described anomaly in which the systemic and pulmonary blood streams cross at the atrioventricular (AV) level, without mixing. A case of criss-cross heart is described in which the right atrium, in a solitus position, communicated with a left-superior positioned, morphologically right ventricle, and the left atrium communicated with a normally located, morphologically left ventricle. The interventricular septum occupied a horizontal plane. Associated defects were complete d-transposition of the great arteries with l-positioned aorta, pulmonary atresia, ventricular septal defect, atrial septal defect, and patent ductus arteriosus. To the best of our knowledge this is the first angiocardiographic demonstration of this rare combination of lesions. The literature on criss-cross heart and horizontal septum is reviewed. It is stressed that regardless of whether the criss-cross phenomenon is an anatomical fact or an angiocardiographic illusion, it is an established angiocardiographic entity and should be recognized as such.