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We have examined 5 patients with typical angina pectoris and found them to have left coronary ostial stenosis without evidence of any other coronary arterial disease and without evidence of aortic disease (Takayasu aortitis, syphilitic aortitis, or familial hypercholesterolaemia). All five patients were female aged between 38 and 53 years, a striking difference from the normal 7:1 male:female ratio for atherosclerotic coronary artery disease. It may be that these patients represent a rare but distinct syndrome. The angiographic diagnosis can be difficult but a pressure drop as the catheter tip engages the ostium and lack of spill-over of contrast into the sinus of Valsalva are findings that should lead the angiographer to suspect ostial stenosis.

A patient is reported with pulmonary arterial occlusions and aneurysms and recurrent haemoptysis. He gave a history of recurrent arthropathy and febrile illnesses; though he had had no other features of Behçet's or Hughes-Stovin syndrome his disease probably fell into this broad diagnostic category.

Two patients with right aortic arch, anomalous left subclavian artery, and coarctation of the aorta, have had operations for the relief of coarctation, successful in one but only partially successful in the other: in one case, a 'dacron' patch was inserted into the narrowed segment, but a mild recurrence of coarctation was found a year later; in the other, the proximal segment of the anomalous left subclavian artery was usedfor the repair, with complete relief of the coarctation, both immediately and at late follow-up.The first case had multiple associated congenital abnormalities, including anomalous origin of the left circumflex coronary artery from the right pulmonary artery, which was also corrected surgically: this anomaly has only been recorded once hitherto. The second had facial haemangiomata and a small ventricular septal defect.Four previously reported cases of coarctation and right arch are reviewed. These 6 cases are considered in the light of current views on the development and classification of aortic arch anomalies.

The association of significant aortic stenosis with mitral stenosis in rheumatic heart disease is not very common. It is, however, important to recognize the presence of the accompanying aortic stenosis and to be able to assess its severity, since this lesion also can be relieved surgically. The clinical and hmmodynamic features of 35 patients, seen at Guy's Hospital between 1952 and 1959, with this combination of lesions have been studied in order to learn more about the ways in which each lesion modifies the effects of the other: these observations have been applied to the problems of diagnosis and assessment of severity. MATERIAL AND METHODSThis series includes those patients (32) in whom an estimate of the mitral valve area has been made by the surgeon, and in whom aortic stenosis was suspected clinically and confirmed by the demonstration of a systolic gradient across the aortic valve, at operation for mitral or combined mitral and aortic valvotomy. Seventeen of these had a pre-operative right heart catheterization, together with a left ventricular puncture in three and a left atrial puncture in three. Two unoperated patients have had full heamodynamic assessment by left atrial puncture; one of these died while awaiting operation and one was thought not to require surgical relief of either stenosis. In one operated patient, a small aortic valve gradient was demonstrated at left atrial puncture but not measured at operation.None of the 35 patients had dominant regurgitation at either valve. In 23, an early diastolic murmur thought to be due to slight aortic regurgitation was recorded, but in only two was this possibly of haemodynamic significance. In 12 of the 33 operated patients, slight mitral regurgitation was detected, but in none was this sufficient to contraindicate valvotomy; in the 2 unoperated patients, the clinical features suggested dominant mitral stenosis, though both had apical systolic murmurs. Three (Cases 8, 11, and 19) had organic tricuspid stenosis.The presence or absence of those symptoms commonly occurring in lone mitral or aortic stenosis and the degree of disability (criteria of Baker et al., 1952) were noted. The findings on examination were not analysed since this was a retrospective study and only a few of the patients were personally examined before operation. The cardiogram was inspected for evidence of right or left or bi-ventricular hypertrophy; left ventricular hypertrophy (L.V.H.) was regarded as slight when the sum of the amplitudes of the deepest S wave in a right ventricular lead and the tallest R in a left ventricular lead was 35 to 45 mm., and moderate when 46 to 60 mm.; changes in the S-T segment and T wave were of little value since most of the patients were receiving digitalis. The cardiac rhythm was also noted. The chest radiograph was examined for dilatation of the first part of the aorta and pulmonary venous congestion, and the screening report for observations on the presence of left ventricular hypertrophy and mitral or aortic valvar calcification and the aortic a...