An early diastolic murmur thought to indicate functional aortic regurgitation was heard in 7 of 74 consecutive patients with end-stage renal failure assessed for chronic intermittent haemodialysis and transplantation. In all 7 cases the murmur was transient and related to episodes of hypertension and fluid overload and disappeared on correction of these factors. In a further 2 patients aortic regurgitation resulted from a structural abnormality of the aortic valve. Thus, an early diastolic murmur is not uncommon in this situation and does not necessarily indicate organic aortic valve disease which might preclude selection for haemodialysis and transplantation.

Transient early diastolic murmur and end stage renal disease Sir, A transient early diastolic murmur may be heard in patients with end stage renal disease. This was initially attributed to aortic regurgitation secondary to fluid overload.' This view was supported by Alexander and Polak,2 who described the appearance of the murmur in seven patients with end stage renal failure during episodes of fluid overload; their description of the murmur supports their conclusions that it was of aortic origin. We have, however, had a patient in end stage renal failure in whom an early diastolic murmur was associated with episodes of typical pericardial pain while he was salt and water depleted. The murmur was loudest when he lay supine and it was clearly audible all over the praecordium. We believe that this observation supports the hypothesis of Barrett et al.3 that an early diastolic "murmur" may be a pericardial noise indicative of uraemic pericarditis. This possibility was not mentioned by Alexander and Polak. Barrett described eight patients and commented that the murmur was not typical of aortic regurgitation in that it was maximal in intensity at and localised to the cardiac apex and became softer when the patient leaned forward. Aortography in six of the patients identified only one patient with possible aortic regurgitation, while echocardiography showed that in all five patients examined a posterior pericardial effusion was present. They concluded that "the early diastolic murmur of renal failure does not usually arise from functional aortic incompetence but may be a sound of pericardial origin". Barrett's conclusions are not

Patients with acute aortic dissection report often the typical sharp, abrupt chest pain. In some cases, when the disease leads to the coronary malperfusion, the symptoms of acute coronary syndrome may be reported. Low cardiac output as the result of the accompanying coronary flow disturbances can require the mechanical cardiopulmonary support. In some selected cases extracorporeal membrane oxygenation can be successfully used as a bridge to recovery or bridge to decision. The additional advantage of this therapeutic option is the possibility of choice of the cannulation strategy: veno-venous, veno-arterial, veno-pulmonal, central/peripheral. Oxygen delivery can be easily regulated on oxygenator. We present two patients with acute type A aortic dissection and acute coronary syndrome, who recovered thanks to such therapy.Keywords: Aortic dissection; ECMO; Heart failure; Right coronary artery Case ReportA 36-year-old man presented with acute inferior ST-elevation myocardial infarction (STEMI) and aneurysm of the ascending aorta was admitted to our hospital with suspicion of an acute aortic dissection. The diagnosis was confirmed with the computed tomography ( Figure 1). The coronary angiography ( Figure 2) showed proximal closure of the right coronary artery (RCA). The modified Bentall operation using the mechanical valve conduit was performed under cardiopulmonary bypass (CPB) and mild hypothermia (32°C). Intraoperative detach of the right coronary artery orifice from the Valsalva sinus was demonstrated. This vessel was ligated and bypassed with a saphenous vein graft.Postoperative the patient needed the NO-ventilation and inotropic agents to maintain the function of the right ventricle. 14 hours after leaving the operating room the veno-venous extracorporeal membrane oxygenation (ECMO) pump implantation was carried out because of hypoxia (PaO 2 /FiO 2 =45) despite the FiO 2 of 100% on respirator. Under gas flow of 2.5 L/min and FiO 2 of 100% on ECMO we achieved an immediate improvement of the arterial oxygenation with PO 2 of 197 mmHg. The central venous pressure dropped rapidly from 26 mmHg to 8 mmHg.The patient underwent bronchoscopy and some bronchial secretion was removed. The echo examination revealed the dilated, poor-functioning right ventricle. On the 12th postoperative day the percutaneous tracheostomy was performed and the patient was successfully weaned from ECMO on the day 18th after the operation. The series of repeated echo examinations showed a distinct improvement of the right ventricular function. Our patient was mobilized and without neurological deficits discharged to internal medicine unit on the 27th postoperative day.A 64-year-old man with the coronary heart disease, who was diagnosed with acute myocardial infarction without ST-elevation (NSTEMI), underwent the echo examination that showed the dissection of the ascending aorta. The patient was admitted to our institution and the modified Bentall operation was carried out under CPB and moderate hypothermia (27°C). The dissection entr...

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