A 62-year-old female patient with known mitral-valve prolapse for the previous five years presented with progressive dyspnea and intermittent palpitations. This clinical presentation was investigated by two-dimensional echocardiography which revealed moderate mitral regurgitation due to a pedunculated mass oscillating between the left atrium and the left ventricle. Successful operative treatment consisted of en-bloc resection of the tumor from the anterior mitral valve leaflet and its primary cords and subsequent reconstruction of the mitral valve. Pathohistological examination revealed a cystic lymphangioma originating from mitral-valve tissue. To our knowledge this is the first reported case in the literature.

The aim of this study was to evaluate the incidence of postoperative pulmonary supravalvular stenosis in patients with d-TGA and to assess the rate of success or failure of balloon angioplasty. Out of 70 patients with d-TGA 67 patients underwent successful arterial switch operation. Twelve children developed severe supravalvular pulmonary stenosis with a peak gradient above 50 mmHg (range: 50-120 mmHg). In these patients 19 high pressure dilatations were performed up to a diameter of 130% of the native valve dimension. The mean age at angioplasty was 17 months (range: 3-36 months). Successful intervention was defined as a > 50% decrease of predilatation peak pressure gradient or right ventricular pressure < 50 mmHg. Dilatations were performed without complications. Complete resolution was primarily achieved in 1 patient. In 7 patients the pressure gradients could be reduced to 10-45 mmHg (mean: 25 mmHg). In another two patients a palliative stent-implantation into the pulmonary trunk was necessary to reduce the pressure gradient. Because unsuccessful intervention, two patients needed subsequent operation. During follow-up of 6-9 months after intervention severe restenosis occurred in 3 patients (2 after stent-implantation; 1 after re-re-dilatation) who then also needed operation. Balloon dilatation should be the first treatment in patients with pulmonary stenosis after ASO in TGA owing to the low complication rate and the potential benefit of this procedure. Recurrent and combined stenoses with narrow pulmonary valve annulus should be treated surgically.

We present the case of a 64 year old man, previously of good health, who presented in November 1995 with a short history of presyncope and one witnessed episode of syncope. On admission he was clinically in complete heart block with a ventricular rate of 40 beats/min but had a well maintained blood pressure at 150/80 mm Hg. Auscultation revealed a soft systolic murmur in the aortic area. The remainder of the examination was unremarkable. Resting ECG confirmed complete AV block with a slow regular broad complex ventricular escape rhythm. A Paragon III (Pacesetter, Coventry, UK) dual chamber pacemaker was subsequently implanted with complete resolution of cardiac symptoms.He remained well for three months when he presented with sudden onset dyspnoea in January 1996. Further examination at this time revealed signs of pulmonary congestion and a cardiac murmur throughout systole and diastole that had changed in character from the previous evaluation. There were no peripheral signs of infective endocarditis. Initial management with intravenous diuretics resulted in rapid clinical improvement and allowed the following sequence of investigations:+ ECG confirmed normal AV sequential pacing. + Transthoracic echocardiography revealed a left ventricle of normal dimension and function. A subaortic membrane of uncertain aetiology was seen and appeared to be attached to the interventricular septum. Aortic regurgitation was confirmed. + Transoesophageal echocardiography revealed an abnormal aortic valve with a large apparently cystic mass under the aortic root, attached inferiorly to the interventricular septum (fig 1). This structure was felt to be a large aneurysm of the right coronary sinus extending into the interventricular septum. + Cardiac catheterisation demonstrated a normal coronary arterial tree but confirmed the presence of a large saccular aneurysm of the right coronary sinus, shown best in the lateral position. Severe aortic regurgitation was seen. The patient was referred for cardiac surgery and at operation a large aneurysm of the right coronary sinus invading the interventricular septum was confirmed. The walls of the sac were intact. The aortic valve itself was tricuspid and normal except that the right coronary cusp was noticeably redundant and was sagging into the left ventricular cavity (fig 1). The aortic valve and aneurysm were excised and the valve replaced with a Carbomedics mechanical prosthesis (East Crawley, West Sussex, UK) under full cardiopulmonary bypass. The patient made an uncomplicated recovery and remains well. DiscussionSinus of Valsalva aneurysm is an uncommon condition usually caused by a congenital defect of continuity between the aortic media and the aortic fibrous ring. Secondary causes are rare but include bacterial endocarditis, syphilis, tuberculosis, and Behçet's disease. 1 2 Surgical treatment is required in nearly all cases with the long term results being favourable; one large series showed a 95% 20 year survival. 3 The classic presentation of a ruptured sinus of Valsalva aneur...

The extended transseptal approach to the mitral valve was used in 32 patients undergoing isolated or combined mitral valve surgery. In all cases exposure of the entire mitral valvular apparatus was excellent. Two patients died of low output within 30 days of surgery. No cause of death was related to the extended transseptal approach. In one early patient reexploration revealed arterial bleeding from the right atrial suture line which was caused by damage to the sinus nodal artery. In 7 patients temporary atrial conduction disturbances occurred which completely resolved within 10 days after responding well to dual-chamber pacing. Temporary ventricular pacing was necessary in two patients with preoperative bradyarrhythmia. In two patients undergoing mitral re-do surgery a permanent ventricular pacer was implanted. The extended transseptal approach offers an excellent exposure of the entire mitral valve both in primary isolated or combined mitral surgery particularly in re-do surgery where the primary standard vertical left atriotomy is impeded or the conventional transseptal approach gives only limited access. Temporary atrial dysrhythmia is not crucial and is easily controlled by short-term dual-chamber pacing.

A retrospective analysis of 127 patients with impending myocardial infarction undergoing coronary artery bypass grafting was performed to evaluate incremental risk factors associated with perioperative mortality and morbidity. Fifty-four patients (group 1) were operated upon as emergencies within 24 h and 73 patients underwent urgent coronary revascularization within a mean of 3.4 days (group II) after admission. The incidence of non-transmural myocardial infarctions (NTMI), haemodynamic parameters, the number of diseased vessels and the incidence of a preceding percutaneous coronary dilatation (PTCA) were not statistically different between the groups. The overall perioperative mortality was 8.7% (16.7% group I, 2.7% group II). Major non-fatal complications were frequent in the surviving collective including low cardiac output in 14 patients (12.1%) and transmural or subendocardial perioperative infarction in 12 patients (10.3%). Perioperative mortality was associated with reduced left ventricular myocardial function (P less than 0.001), operation within 24 hr after onset of anginal symptoms (P less than 0.001) or subendocardial infarction (P less than 0.025) in the 4 weeks before operation. Perioperative mortality was independent of the degree of coronary stenosis, number of distal anastomoses or performance of a coronary endarterectomy. Of the patients, 90.5% (87.5% of group I and 92.3% of group II) included in a mean follow-up of 16.8 months (range 5-27 months) were graded into Canadian Heart Functional Class I. Successful coronary surgery for acute myocardial ischaemia results in excellent late functional recovery. The major risk factors for fatal perioperative outcome are reduced left ventricular function and the necessity of every early surgical intervention.