Objective-To assess the value of necropsy examination in patients dying soon after cardiac surgery, particularly the proportion of clinical questions answered by the necropsy, the frequency of major unexpected findings, and the limitations of the procedure. Design-A three year prospective study of necropsy examinations in adult patients dying before discharge or within 30 days of cardiac surgery performed under cardiopulmonary bypass in one hospital. Setting-Tertiary referral centre. Results-123 of 2781 patients (4.4%) died in the early postoperative period, and necropsy examination was performed in 108 of these (88%). The mortality after emergency procedures (18%) was much higher than after routine operations (2.6%). The main causes of death were cardiac failure (52%), haemorrhage (14%), cerebral disease (6%), and pulmonary emboli (5%). The necropsy changed the stated cause of death in 16 patients (15%), and answered clinical questions in 24 of 38 patients. In 15 patients necropsy examination did not provide a full explanation of death. Most of these patients died of cardiac failure soon after surgery or were sudden unexpected deaths. Conclusions-Necropsy examination in patients dying early after cardiac surgery is valuable as it answers the majority of clinical questions, and shows unexpected findings in a significant proportion of cases.

We present the case of a 19-year-old student who underwent correction of a pectus excavatum deformity using a pectus bar. At least 6 months following surgery, one end of the bar had migrated into his right ventricle, across the interventricular septum, to lie with its free end in the left ventricular cavity. This acted as a source of thrombus formation and lead to several systemic embolic events. The patient made a full recovery after removal of the bar. A review of the literature demonstrates that this has not been reported before.

In a consecutive series of 149 patients with congenital ventricular septal defect (VSD), temporary tricuspid valve detachment was applied in 39 (detached group) to facilitate the transatrial approach for closure of the defect. Baseline characteristics showed that, preoperatively, the detached group were younger (1.3 +/- 2.3 vs. 3.5 +/- 4.1 years, P = 0.002), shorter (0.67 +/- 0.20 vs 0.87 +/- 0.34 m, P = 0.001), lighter (6.9 +/- 5.4 vs 13.5 +/- 12.0 kg, P < 0.002), and had a higher mean right atrial pressure (6 +/- 2 vs 4 +/- 3 mm Hg, P < 0.003), mean end-diastolic right ventricular pressure (10 +/- 3 vs 8 +/- 3 mm Hg, P < 0.01) and mean pulmonary vascular resistance (267 +/- 202 vs 170 +/- 131 dyn s cm-5, P < 0.02) on cardiac catheterization. At surgery the aortic cross-clamp time was longer (48 +/- 17 vs 39 +/- 15 min, P = 0.003). Seven patients died (2 detached, 5 not-detached), from causes not related to either tricuspid detachment or VSD closure. Follow-up was complete with a mean duration of 2.0 years (range 0.1-5.5). All 142 survivors were investigated by echocardiography, which showed normal tricuspid valve function in all but 29 patients who had trivial regurgitation (6 detached, 23 not-detached). There was no tricuspid stenosis. In 30 patients (8 detached, 22 not-detached) a trivial residual VSD could be detected. One reoperation (not-detached) was performed 12.5 months after the initial surgery for recurrent VSD.(ABSTRACT TRUNCATED AT 250 WORDS)

SUMMARY A patient with pseudoxanthoma elasticum presented in pulmonary oedema with restrictive left ventricular cardiomyopathy caused by calcified endocardial bands that were confirmed on echocardiography and at catheterisation. The bands were resected as far as possible and the involved mitral valve was replaced by a heterograft. A year later calcification of the heterograft forced its replacement by a St Jude prosthesis. Relief of symptoms has been good in the medium term.Case report A 27 year old white man, known to have pseudoxanthoma elasticum, presented with a rapidly progressive nine month history of exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, and the striking symptom of exertional haemoptysis. Over the nine month period his exercise tolerance had decreased from that of an active amateur footballer to being unable to walk more than one hundred yards on the flat.Physical examination showed the classic skin lesions of pseudoxanthoma elasticum-yellow pseudoxanthomatous plaques, mainly in the neck region. There was evidence of congestive cardiac failure, with a sinus tachycardia, a loud left ventricular third heart sound, bilateral basal crepitations, jugular venous pressure raised 3-4cm with a deep "y" descent, an enlarged pulsatile liver, and oedema of the legs. The electrocardiogram showed no abnormality and in particular the QRS complexes and T waves were normal. The chest x ray showed considerable calcification within the cardiac outline-in particular in the region of the left ventricle ( figure). The classic appearances of pulmonary oedema were present. Cross sectional and M mode echocardiography showed several abnormal features (

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