After cardiac surgery transoesophageal echocardiography showed a large thrombus compressing the right atrium in 'three hypotensive patients. No satisfactory images were obtained by transthoracic imaging, which is often difficult in ventilated patients after cardiac surgery. Transoesophageal echocardiography, however, provided rapid diagnostic information and permitted prompt surgical intervention.In patients who become hypotensive after major cardiac surgery it is often not easy to make the differential diagnosis between left ventricular dysfunction, prosthetic valve dysfunction, sepsis, cardiac tamponade, and intrathoracic bleeding. Echocardiography can provide additional information about the contractile state of the left ventricle and the function of prosthetic valves but transthoracic imaging in a ventilated patient after cardiac surgery is difficult. Transoesophageal echocardiography provides rapid, real time high resolution imaging of the heart and surrounding structures that is valuable in the management of these patients.We describe three patients in whom compression of the right atrium by localised haematoma formation presented as either an early or late postoperative complication of valve surgery and in whom transoesophageal echocardiography was of primary diagnostic importance. 1). Colour Doppler flow mapping showed that the right atrial cavity was less than 1 cm in diameter. The right ventricle and the left heart were underfilled and the mitral valve prosthesis seemed to be functioning normally. At reoperation the transoesophageal echocardiographic findings were confirmed and direct left atrial puncture showed a left atrial pressure of 5 mm Hg. The large haematoma was removed and haemostasis secured. The patient subsequently made an uneventful postoperative recovery. CASE 2A 66 year old man who had had a CarpentierEdwards aortic valve replacement for aortic regurgitation and dilatation of the ascending aorta 10 years previously had the prosthetic valve replaced by a number 12 Starr-Edwards valve. The operative procedure was uncomplicated and the patient had an uneventful postoperative course. He was discharged seven days after operation. He was readmitted three days later with a history of increasing shortness of breath, a heart rate of 120 beats/ min, and a systolic blood pressure of 70-80 mm Hg. There were no clinical signs of valve dysfunction or chest infection. The electrocardiogram showed atrial fibrillation with a rapid ventricular response and the chest x ray showed some cardiomegaly but clear lung fields. Echocardiography showed a large haematoma surrounding and compressing the right atrium, like that in patient 1. At reoperation there was a large clot compressing the right atrium contained by a partially obliterated pericardium. The source

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Experimental cardiac infarction produced in dogs by coronary artery ligation has been used to investigate the value of macroscopic histochemical enzyme loss in the diagnosis of myocardial infarction at post-mortem. Creative phosphokinase and non-specific dehydrogenase methods gave the best results but became positive only 5-6 hr after infarction. It is concluded that the method is of limited value in autopsy practice.

Nearly all forms of valve surgery are incompatible with fitness to fly. The biological valves have a small but definite thrombo-embolic risk and are prone to late failure. The prosthetic valves require long-term anticoagulant therapy and carry an unacceptable risk of thrombo-embolism. The only possible exception is the unmounted homograft in the aortic position. If two years after such a valve replacement a patient can be shown to have a normal resting electrocardiogram, a normal chest X-ray, a normal exercise stress test, a normal echocardiographic left ventricular chamber size and wall thickness and evidence of no significant gradient across the valve, consideration should be given to certification for multi-crew operation, subject to annual examination by a cardiologist. A satisfactory open mitral valvotomy with obliteration of the left atrial appendage in an airman in sinus rhythm might allow certification to fly 'as or with co-pilot', subject to strict annual review which should include clinical cardiological examination, echocardiography and exercise electrocardiography. Satisfactory conservative repair of the 'floppy' mitral valve with no clinical or echocardiographic evidence of significant residual mitral regurgitation may similarly allow a return to flying with a restricted licence .

The prognosis following coronary artery bypass grafting (CABG) is still being established in the long term. Graft-attrition occurs at a rate of 10% per annum in the first year, falling to 2-3% per annum in the second and subsequent years. Only 46% of symptomatic individuals treated surgically in one series were symptom-free at five years but newer surgical techniques may improve this figure. The risk of graft-atheroma increases with time as does the risk of atheroma in the native circulation. Nevertheless, sudden late cardiac death was not observed in the three to five year follow-up in the surgical group of the European Coronary Surgery Study Group. It is suggested that a pilot may be considered for certification for multi-crew operation 12 months after CABG, subject to the demonstration of a normal contrast ventriculogram, patent grafts without other significant disease, and a normal exercise electrocardiogram and exercise thallium 201 scan. Follow-up should be by six-monthly exercise electrocardiography and annual thallium scanning. A coronary angiogram should be performed not more than five years after recertification. The intermediate and long-term prognosis following percutaneous transluminal angioplasty is unknown.