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Originally described in 1964, lipomatous hypertrophy of the atrial septum currently remains a diagnosis established primarily at autopsy. Clinical interest in this disorder has centered on the reported association with supraventricular arrhythmias and sudden death. Because two-dimensional echocardiography allows detailed assessment of atrial septal configuration, we reviewed two-dimensional echocardiographic reports obtained over a 1 year period and identified 17 patients who had features consistent with lipomatous hypertrophy of the atrial septum. Nine were men and the average age was 70 years. Autopsy confirmation of the echographic findings was possible in one patient. In nine patients, ideal body weight was exceeded by 10% or more. The atrial septum viewed from the subcostal transducer position showed a distinctive echo-dense globular thickening sparing the valve of the fossa ovalis. The resultant tomographic image of the atrial septum had a characteristic dumbbell appearance. The mean thickness of the atrial septum was 21 mm (range 15 to 29). Seven patients had supraventricular arrhythmias, and eight had P wave abnormalities. The two-dimensional echocardiographic features described are distinctive and suggest that this technique is the procedure of choice not only for establishing the diagnosis of lipomatous hypertrophy of the atrial septum but also for providing a means for prospective follow-up of patients with this little known entity.

SUMMARY From January 1954 to December 1985 cardiac myxoma was diagnosed in 75 patients at the Mayo Clinic. The clinical presentation was typical in 70 cases and was referred to as "sporadic myxoma". Forty four other cases of cardiac myxomas (five from the Mayo Clinic) presented with a combination of distinctive clinical features and these cases are described as "syndrome myxoma". The patients with syndrome myxoma were younger (mean age, 25 vs 56 years) and had unusual skin freckling (68%), associated benign non-cardiac myxomatous tumours (57%), endocrine neoplasms (30%), and a high frequency of familial cardiac myxoma (25%) and familial endocrine tumours (14%). The two types of cardiac tumour were different (syndrome vs sporadic): atrial location, 87% vs 100%; ventricular location, 13% vs 0%; single tumour, 50% vs 99O%; multiple tumours, 50%/ vs 1%; and recurrent tumour, 18% vs 0%.

Recent reports have raised concern over the use of standard subclavian puncture for placement of permanent pacing leads. This study reports the initial experience of one implanter in 59 consecutive, unselected patients undergoing implantation of a variety of pacing leads in whom a simple Doppler flow detector was used to guide extrathoracic venipuncture of the lateral subclavian/axillary vein. A total of 100 leads were placed for 48 right- and 11 left-sided systems. Lead insertion by this technique was successful in all patients. One small pneumothorax and two uncomplicated arterial punctures occurred. One patient's leads were revised electively because of unacceptable loss of redundancy when standing. There have been no infections or other late complications. A simple Doppler flow detector appears to be useful in identifying the lateral subclavian/axillary vein for extrathoracic pacemaker lead placement.

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