A 75-year-old woman presented with new onset of angina at rest associated with shortness of breath. The physical examination was significant for jugular venous distension and rales in both lungs. The chest radiogram showed bilateral lung congestion. She had ischemic ECG ST-segment and T-wave changes and serum creatine kinase-MB enzyme elevation consistent with a non-Qwave myocardial infarction. Transthoracic echocardiography documented severe posterolateral and mild anteroseptal hypocontractility, with mild overall left ventricular function and mild aortic regurgitation. Because the symptoms were refractory to medical therapy, the patient was referred for cardiac catheterization. The coronary arteries appeared angiographically normal. However, the patient experienced severe chest pain at the end of the procedure. Repeat left coronary injection revealed a severe stenosis of the left main coronary artery, and the arterial blood pressure tracing was damped ( Figure 1); intracoronary nitroglycerin had no effect. The patient continued to have severe angina, worse ischemic ECG changes, and progres-sive bradycardia and hypotension, warranting placement of a perfusion balloon in the left main coronary artery and insertion of an intra-aortic balloon pump and a temporary pacemaker. She was referred for emergent open-heart surgery with the presumptive diagnosis of catheterinduced dissection of the left aortocoronary ostium.Immediately after induction of anesthesia, a routine intraoperative transesophageal echocardiogram demonstrated a highly mobile round mass at the left coronary cusp of the aortic valve ( Figure 2). The mass appeared to obstruct the left coronary ostium in early diastole ( Figure 2C and 2D). The surgical approach was altered accordingly. Inspection showed a mass attached to the left coronary cusp of the aortic valve ( Figure 3); the left coronary ostium appeared normal. The patient underwent aortic valve replacement with a bioprosthetic valve, and no aortocoronary bypass grafts were required. Histological examination ( Figure 4) showed a papillary fibroelastoma of the aortic valve, also referred to as giant Lambl's excrescences, fibroelastic hamartoma, or papilliferous tumor.

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Planktic foraminifera are commonly used for first-order age control in deep-sea sediments from low-latitude regions based on a robust tropical–subtropical zonation scheme. Although multiple Neogene planktic foraminiferal biostratigraphic zonations for mid-latitude regions exist, quantification of diachroneity for the species used as datums to test paleobiogeographic patterns of origination and dispersal is lacking. Here, we update the age models for seven southwest-Pacific deep-sea sites using calcareous nannofossil and bolboform biostratigraphy and magnetostratigraphy, and use 11 sites between 37.9° N and 40.6° S in the western Pacific to correlate existing planktic foraminiferal biozonations and quantify the diachroneity of species used as datums. For the first time, northwest and southwest Pacific biozones are correlated and compared to the global tropical planktic foraminiferal biozonation. We find a high degree of diachroneity in the western Pacific, within and between the northwest and southwest regions, and between the western Pacific and the tropical zonation. Importantly, some datums that are found to be diachronous between regions have reduced diachroneity within regions. Much work remains to refine regional planktic foraminiferal biozonations and more fully understand diachroneity between the tropics and mid-latitudes. This study indicates that diachroneity is the rule for Late Neogene planktic foraminifera, rather than the exception, in mid-latitude regions.