Among the different anatomical forms of anomalous pulmonary venous return, that of the inferior vena cava is of particular interest for the following reasons: the special radiological pattern which is referred to as the scimitar sign and the associated anomalies which often occur in the lungs. We have successfully operated on three' patients who are reported in this paper, and we have included a review of the literature. CASE REPORTS CASE 1 Liliane D., aged 9, presented because of repeated episodes of 'bronchitis' since infancy. At the age of 2 years a diagnosis of atrial septal defect (A.S.D.) had been made. On examination she was noted to have retarded development and some bulging of the left hemithorax. On auscultation she had a systolic murmur of moderate degree in the second and third intercostal spaces on the left, radiating towards both axillae and the back and of maximum intensity in the right axilla. On radiography (Fig. 1) the right border of the heart was predominantly enlarged, showing increased vascularization and also an opacity along the right cardiac border. The electrocardiogram showed right axis deviation and hypertrophy of the right ventricle.Catheterization confirmed the existence of an A.S.D. of ostium secundum type. There was a leftto-right shunt of 3 volumes, and moderate elevation of the pulmonary artery pressure. The right ventricular pressure was 48 mm. Hg. Stenosis of the right pulmonary artery with a gradient of 20 mm. Hg across the obstruction was also found. Right anomalous pulmonary venous drainage was found, but the exact site was not known.Operation was performed on 18 September 1963, using a mid-sternal incision and extracorporeal circulation with a moderate degree of hypothermia. Findings at operation included a huge right atrial chamber, and a small aorta and superior vena cava.On opening the right pleural space it became evident 'Recently, a fourth patient has been successfully operated on.

Bilateral internal thoracic artery grafting with skeletonized harvesting carried low post-operative mortality and morbidity and therefore it could be applied routinely without the fear of increased complication rate.

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Over a 17-year period (1970-1987) 75 patients, 3% of overall valvular surgery (VS) patients have been permanently paced at the time of VS (group 1), nine have been paced long after (group 2), 12 were already paced at the time of valve replacement (group 3), and 81 had a permanent pacing lead inserted during VS without further need for permanent pacing (group 4). Based on pre-, per- and post-operative clinical and electrocardiographic data we studied these four groups (GR). Aortic disease and especially calcified aortic stenosis (CAS) are the main valvular pathologies in all GR. The survival rate in GR 1 is lower than the survival rate of our overall VS PT5 due to older average ages and more severe cardiac conditions. In five patients GR 2 a myocardial pacing lead placed during VS was used long after for permanent stimulation. Patients in GR 3 were older than in other GR at the time of VS. The mortality was high in the patients operated on between 1973 and 1978 (average survived 3.5 years after pacing/2 years after VS) thus demonstrating the benefit of myocardial protection. For GR 4 the ratio of permanent lead implantation during VS was high in the late seventies (10%), it is now around 0.5%. In cases where the evolution of peroperative conduction disturbances is doubtful, it seems to us simpler to place a myocardial lead avoiding subsequent endocardial pacing if necessary, later, especially in patients with tricuspid disease.