Clinical cardiac procedures such as electrophysiology studies, catheter ablation of arrhythmias, retrograde cardioplegia delivery, cardiac resynchronization therapy and, more recently, percutaneous mitral annuloplasty, involve cannulation of the coronary sinus (CS). The presence of a membrane closing the orifice of the CS may cause difficulties during these interventions. Thus, detailed knowledge of the variations and anomalies of the valve of the CS, or the Thebesian valve, now has practical significance. To improve our understanding of this structure, classic anatomical dissection of 50 hearts from dissection room cadavers was performed. A Thebesian valve was present in the overwhelming majority (88%) of cases. Its morphology varied widely, from a few small strands of tissue, to a membrane covering more than half the CS ostium. A significant number (20%) of valves occluded >65% of the ostium, making them "potential complicating factors" in cannulation of the CS. An understanding of these anatomical variations may help in identifying and overcoming potential difficulties during clinical cardiac interventions.

A 73-year-old nonhypertensive man was admitted to the GB Pant Hospital for chest pain and dyspnea on exertion. Transthoracic echocardiography revealed severe mitral regurgitation with mild aortic stenosis (mean gradient, 24 mm Hg) and concentric left ventricular hypertrophy (LVH). The ejection fraction was 0.67. Mitral valve replacement with intraoperative transesophageal echocardiography was planned. During surgery, gross hypertrophy of the anterolateral papillary muscle (Figure 1) was found, which prompted a review of the patient's charts. Apart from increased voltages consistent with LVH, electrocardiogram revealed a peculiar pattern in leads V3 and V4: prominent, positive U waves that were missed on initial evaluation (Figure 2).Hypertrophic cardiomyopathy (HCM) is a highly heterogeneous disorder with mutations in genes coding for proteins of the cardiac sarcomere, manifesting as LVH without obvious cause. 1 Papillary muscle hypertrophy and positive U waves are rare but documented features of HCM. 2 In view of the patient's age, nonobstructive nature of his disease, and absence of atrial fibrillation, no further surgical intervention was planned. Because calcium antagonists are the preferred therapy for nonobstructive HCM with normal systolic function, 1 the patient was prescribed oral diltiazem postoperatively. He was discharged uneventfully and continues to do well on follow-up.

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A 40-year-old woman presented 19 years after ring-annuloplastyfor rheumatic mitral regurgitation. Long-standing rheumatic heartdisease resulted in an unusual finding on her chest radiograph.

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