ACQUIRED tricuspid valvular disease of surgical significance is being recognized and treated successfully with increasing frequency in our clinic. Within the last 18 months five patients with tricuspid insufficiency and mitral stenosis had their lesions corrected with the insertion of a ball valve in the tricuspid area and valvuloplasty or replacement of the mitral valve with no mortality and significant clinical improvement in all. The diagnosis and management of severe organic tricuspid valvular disease in the face of advanced mitral valve lesions has presented certain problems that are discussed herein.

A VENTRICULAR ANEURYSM due to coronary occlusion is not a rare pathologic entity. It was first described by Hunter' in 1757, and Sternberg2 was the first to appreciate the concept of chronic aneurysm and reported the first cases during life. With the development of roentgenology and contrast technics, the disease has become clinically diagnosed niore and more frequently. The incidence has varied between 8 and 22 per cent of all myocardial infarets, depending upon the criteria given by the authors.3 4 The sex incidence has been predominantly male, similar to the ratio in myocardial infaretion. The prognosis has been grave,. with a mortality of 73 per cent within the first 3 years after the initial infaret and rose to 88 per cent in the next 2 years.5 This grim outlook for the left ventricular aneurysm after infaretion is in sharp contrast with coronary occlusive disease without aneurysm formation. Master and co-workers6 found 50 per cent survivals 5 years following the initial infaret, and large numbers of patients were completely rehabilitated. The most frequent cause of death fronm left ventricular aneurysms has been congestive heart failure.5 DeCamp7 first reported a significantly reduced cardiac output in a patient with ventricular aneurysm after infaretion. Unfortunately, his patient succumbed after surgery. A high incidence of mural thrombi has been

Aortico-left ventricular tunnel (ALVT) is an extremely rare congenital entity in which an abnormal communication between the aorta and the left ventricle bypasses the aortic valve. The condition usually results in gross aortic regurgitation, rapid cardiac decompensation, and death. An additional case of ALVT managed by successful surgical repair is described. The 38 cases reported in the literature are reviewed with emphasis on the clinical and pathological features, diagnosis, natural history, and management. Early operation is recommended to prevent distortion of the aortic valve, dilatation of the left ventricle, and distortion of the aortic anulus.

The successful second-replacement of mitral valve prostheses in two children, age 5 and 9 years, is reported. In one, a parachute mitral valve deformity was first corrected at the age of 10 months by the small-size 00 Starr-Edwards prosthesis. The second child had mitral valve disease caused by Marfan's syndrome 1; the valve was initially replaced at the age of 3 years by a size 0 Starr-Edwards prosthesis. For both patients, in the period between the two interventions, the left ventricle had grown in size and the mitral anulus was not a limiting factor in the insertion of a larger prosthesis of the Björk-Shiley type. Follow-up periods of 1 and 6 years, respectively, confirm excellent clinical results. Problems concerning valve replacements in pediatric patients are discussed.

Thirteen cases of diaphragmatic rupture following blunt trauma or gunshot wounds are presented. In 10 cases the diagnosis of diaphragmatic rupture was made immediately following the injury, and the defect was closed by primary diaphragmatic suture. In three cases, the diagnosis was delayed for 3 to 16 years after the initial trauma. In all of them, abdominal organs such as the colon or liver had migrated into the thoracic cavity. One of them had acute intestinal obstruction and died following several unsuccessful operations. The remaining two patients required plastic repair of the diaphragmatic hernia by a Dacron patch, and both recovered. The clinical and pathological aspects of diaphragmatic rupture, the importance of early diagnosis and surgical correction, and the surgical approach to this entity are considered. The use of Dacron fabric in delayed closure of diaphragmatic defects is described.

This 33-year-old man developed fever, cough productive of yellow sputum, and bilateral chest pain ten days before admission. Physical examination gave normal findings .

Between the years 1964 and 1970, 45 consecutive patients, 24 males and 21 females, with ages ranging between 7 months and 74 years, were operated upon for mediastinal tumours. Fourteen per cent of the patients were asymptomatic and their lesions were detected on routine chest X-ray films. The clinical and pathological findings spanned a wide variety of tumours. Fourteen patients (31%) of the 45 were classified as malignant. Two patients (4.4%) died early in the postoperative period and four (8.8%) later—9 months to 4 years following operation. All the late deaths were patients with malignant lesions.

Ebstein's anomaly has been reported in a family affecting a brother and a sister. The rest of the family members, including the nonidentical twin brother of the second patient, were free of symptoms. The clinical and hemodynamic data indicated Ebstein's anomaly in both. This was confirmed on necropsy of the first patient and at operation in the second, in whom a prosthetic valve replacing the tricuspid was inserted at the age of 13 years. This patient also died eight months following operation. Despite this outcome and from the experience of others, it is our belief that certain cases of Ebstein's anomaly may be amenable to surgical treatment. The available surgical procedures and the indications for operation are briefly discussed.

Summary 1. Glomerular filtration rates and effective renal plasma flows were determined pre- and postoperatively in 31 patients undergoing heart surgery and correlated with plasma norepinephrine and epinephrine levels during corrective surgery. 2. It appears that an increased level of catecholamines is responsible in part for the efferent arteriolar constriction seen in patients with chronic heart disease. 3. Dibenzyline appeared to be effective in preventing postoperative renal ischemia by inhibiting norepinephrine and epinephrine action upon the renal vasculature. 4. In the postoperative period in 27 patients receiving Dibenzyline, a dramatic reduction in glomerular filtration rate was noted, while the effective renal plasma flow was not significantly changed, even though plasma catecholamine concentrations were noted to increase significantly. Possible mechanisms for these phenomena are discussed.

A Starr-Edwards mitral valve of orifice area 1.53 cm. 2 was successfully inserted to replace [see figure in the PDF file] [see table in the PDF file] a "parachute" mitral valve producing clinically significant mitral stenosis.

COMPREHENSIVE assessment of the aortic valve in severe valvular stenosis, in the presence of peripheral arteriosclerosis and in infants is difficult or impossible by the "retrograde" approach through the aortic valve. In these circumstances various technics for puncture of the left ventricle1 , 2 or the left atrium3 4 5 have been applied that have offered less opportunity for selective angiography and have resulted in a relatively higher morbidity and mortality. The transseptal technic6 , 7 offers an excellent and safe approach for assessment of the mitral valve but is less satisfactory for complete aortic-valve evaluation.Our approach consists of introducing a small and short catheter . . .