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SUMMARY A 38 year old woman previously known to have a heart murmur presented with malaise and bloodstained sputum. Echocardiographic examination showed a subpulmonary ventricular septal defect and probable vegetations on the pulmonary valve, and blood cultures grew Escherichia coli. She made a full recovery after 6 weeks' antibiotic treatnent.The pulmonary valve is rarely affected by subacute bacterial endocarditis and it is the most difficult of the four cardiac valves to visualise by echocardiography. Consequently there are few reports of the echocardiographic demonstration of pulmonary valve vegetations. We present an unusual case in which pulmonary valve vegetations were found in association with a jet lesion from a subpulmonary ventricular septal defect. Case reportA 38 year old Greek woman with a three month history of general malaise and myalgia and a cough productive of bloodstained sputum who had been told she had a congenital heart lesion travelled to the United Kingdom to seek medical advice.On examination she was generally well with no stigmata of subacute bacterial endocarditis. Her blood pressure was 120/90 mm Hg with a heart rate of 72 beats/min. There was a loud pansystolic murmur with an associated thrill at the left stemal edge and a soft early diastolic murmur over the pulmonary area that was best heard in inspiration. Her chest x ray showed an enlarged cardiac shadow and pulmonary plethora, but no evidence of pulmonary emboli. The electrocardiogram was within normal limits. A cross sectional echocardiogram showed a ventricular septal defect below the pulmonary valve (Fig. 1), and the presence of a high-velocity jet across this lesion was confirmed with pulsed

A total of 25 CarboMedics bileaflet prostheses was studied in the immediate postoperative period and at 1 week, 1 month and 3 months after surgery. No evidence of rotation was found on visual comparison of valve orientation and there were no significant differences between successive studies for the distance between the septum and either the anterior (P = 0.92) or posterior leaflet (P = 1.00) of valves in the mitral position. The possibility of spontaneous rotation is a potential drawback not only of the CarboMedics prosthesis, but also of designs currently being developed. This study suggests that major rotation does not occur commonly.

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SUMMARY Stress echocardiography has a number of advantages over exercise electrocardiography. It has superior sensitivity and specificity as it detects wall motion abnormalities, an earlier and more specific marker for myocardial ischaemia than ST segment depression. It can also localise ischaemia and identify hibernating myocardium. Compared with radionuclide imaging, stress echocardiography has similar accuracy but is cheaper and does not involve exposure to ionising radiation. The disadvantage of stress echocardiograph is that it requires expertise and specialist experience of at least 100 studies. Current research aims at improving objective methods of analysing results. The technique is justifiably being adopted throughout the UK.