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1 The favourable haemodynamic effects of captopril in patients with congestive heart failure have been reported. 2 We have treated 25 patients with severe chronic congestive heart failure with captopril in doses of 75-450 mg daily. Before entering the study all patients remained in New York Heart Association functional class IV despite high- dose diuretic and vasodilator therapy. 3 Mean cardiothoracic ratio was 60%, and all patients had a shortening fraction of 18% or less on echocardiography (normal 25 to 40%). 4 Five patients died within one month of captopril and five between four and seven months, three of whom had improved to class IIM and one to IIS before death. 5 Of the 15 survivors one was referred for a heart transplant when he had improved to class IIM. The remaining 14 patients were followed for 8-16 months. Ten improved to New York Heart Association class I or IIS and four to class IIM or III. Diuretic requirements were decreased considerably in all 14. Side effects were common but captopril did not have to be withdrawn. Captopril is a highly effective drug in the treatment of patients with congestive heart failure refractory to currently accepted therapy. [ABSTRACT FROM AUTHOR]

Extreme climatic events and land-use change are known to influence strongly the current carbon cycle of Amazonia, and have the potential to cause significant global climate impacts. This review intends to evaluate the effects of both climate and anthropogenic perturbations on the carbon balance of the Brazilian Amazon and to understand how they interact with each other. By analysing the outputs of the Intergovernmental Panel for Climate Change (IPCC) Assessment Report 4 (AR4) model ensemble, we demonstrate that Amazonian temperatures and water stress are both likely to increase over the 21st Century. Curbing deforestation in the Brazilian Amazon by 62% in 2010 relative to the 1990s mean decreased the Brazilian Amazon's deforestation contribution to global land use carbon emissions from 17% in the 1990s and early 2000s to 9% by 2010. Carbon sources in Amazonia are likely to be dominated by climatic impacts allied with forest fires (48.3% relative contribution) during extreme droughts. The current net carbon sink (net biome productivity, NBP) of +0.16 (ranging from +0.11 to +0.21) Pg C year(-1) in the Brazilian Amazon, equivalent to 13.3% of global carbon emissions from land-use change for 2008, can be negated or reversed during drought years [NBP = -0.06 (-0.31 to +0.01) Pg C year(-1) ]. Therefore, reducing forest fires, in addition to reducing deforestation, would be an important measure for minimizing future emissions. Conversely, doubling the current area of secondary forests and avoiding additional removal of primary forests would help the Amazonian gross forest sink to offset approximately 42% of global land-use change emissions. We conclude that a few strategic environmental policy measures are likely to strengthen the Amazonian net carbon sink with global implications. Moreover, these actions could increase the resilience of the net carbon sink to future increases in drought frequency., (© 2014 The Authors. Biological Reviews © 2014 Cambridge Philosophical Society.)

Background: Coexistent coronary disease can be identified in a third of patients with mitral valve disease. This study aims to evaluate candidate selection strategy using risk factor identification and logistic regression and to develop an additive model for the prediction of coexistent coronary disease., Methods: The sample is a consecutive series of patients who had mitral repair from 1987 to 1999. Sensitivities and specificities were calculated for each risk factor. Variables for prediction of coronary disease were entered into a univariate analysis, and predictors were entered into a forward and backward stepwise multivariate logistic regression model to form a predictive score. An additive model was derived from transformation of the logistic model. Receiver operating characteristic curves were used to compare discrimination and precision quantified by the Hosmer-Lemeshow statistic., Results: The American Heart Association and American College of Cardiology risk factor identification selection criteria for the 359 patients who had screening coronary angiography yielded 100% sensitivity and 1% specificity. Risk prediction with our logistic model produced a receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.4 (p = 0.9). Similar discriminating ability for our patients was achieved by the Cleveland Clinic logistic model (receiver operator characteristic curve area of 0.79; Hosmer-Lemeshow score of 12; p = 0.1). Our five-item additive model produced receiver operating characteristic curve area of 0.91 and Hosmer-Lemeshow score of 3.81 (p = 0.80)., Conclusions: Simple risk factor identification has excellent sensitivity but is limited by specificity. Logistic regression modeling is an accurate risk prediction method but is difficult to apply at the bedside. Simplicity and accuracy may be achieved by the logistic regression-derived simple additive model.

Mitral valve repair is the procedure of choice to correct mitral regurgitation. Most operative techniques use an annuloplasty ring to provide stability and durability to the correction. We present a modification of existing repair techniques, without the use of an annuloplasty ring, in which plication sutures allow both annular remodeling and stability. Clinical and echocardiographic follow-up in our series of 60 patients with a mean follow-up of 29 months is presented.

Objectives: The ability to detect residual regurgitation is important in the management of patients after mitral valve repair. We performed a study of 264 patients to determine the risk factors and to compare the accuracy of clinical assessment with that of echocardiography., Methods: Operative details and valve pathologic data were obtained from individual patient case notes. Clinical assessment consisted of history, examination, and electrocardiography. The presence of regurgitation was ranked in 7 grades, from none to severe. Transthoracic echocardiography was performed blinded to and independently of clinical assessment on the same visit and was graded similarly. Univariate analyses of demographic, etiologic, and operative variables were performed. Significant factors were entered into a multivariate logistic regression model. Sensitivities and specificities were calculated for each diagnostic modality, and the kappa statistic was used to express agreement., Results: Mean (+/- SE) freedoms from regurgitation at 1 and 5 years were 91.5% +/- 1.7% and 47.5% +/- 3.2%. Factors independently associated with postoperative regurgitation were poor ventricular function (P =.04), increased age (P =.01), and chordal procedures (P =.006). When assessing the presence of regurgitation, auscultation conferred a specificity of 78%, a sensitivity of 77%, and a kappa of 0.43 relative to echocardiography. Electrocardiographic criteria for left ventricular hypertrophy were superior, with a complete specificity of 100% but a low sensitivity of 15%. Agreement within 7 grades of severity was moderate, with a weighted kappa value of 0.42., Conclusions: The hazard function for regurgitation after mitral repair increases steadily after the third year, with ventricular function, age and chordal procedures as independent risks. Clinical assessment and electrocardiography are excellent in identifying regurgitation, but their agreement is less when grading severity.

Background: To investigate the outcome of patients in atrial fibrillation (AF) following mitral valve repair, clinical and echocardiographic follow-up was undertaken in 400 consecutive patients who underwent mitral valvuloplasty from 1987 to 1999., Methods and Results: The main indications for surgery were degenerative (81.4%), endocarditis (7.1%), rheumatic (6.6%), ischemic (4.6%), and traumatic (0.3%) mitral valve disease. After excluding 6 paced patients and 1 patient in nodal rhythm, we compared the outcomes of 152 patients in AF against 241 patients in sinus rhythm. For patients in AF versus those in sinus rhythm, more AF patients were older (mean age 67.2+/-8.8 versus 61.9+/-11.8 years, respectively; P<0.001), more were assigned to a poorer New York Heart Association (NYHA) class (77.6% versus 66.0% in NYHA III/IV, respectively; P=0.01), and more demonstrated impaired ventricular function (78.9% versus 46.2% with moderate or severe impairment, respectively; P<0.001). For patients in AF versus those in sinus rhythm, there was no difference in 30-day mortality (2.0% versus 2.1%, respectively; P=0.95), repair failure (5.4% versus 3.6%, respectively; P=0.41), stroke (5.4% versus 2.2%, respectively; P=0.11), or endocarditis (2.3% versus 0.9%, respectively; P=0.27) on follow-up at a median of 2.8 years (interquartile range 1.1 to 6.0). On echocardiography, the proportion of patients with mild regurgitation or worse was 13.3% (AF patients) versus 10.8% (patients in sinus rhythm) (P=0.70). Patients in AF versus those in sinus rhythm had lower survival at 3 years (83% versus 93%, respectively) and 5 years (73% versus 88%, respectively). Univariate analysis identified factors affecting survival as AF (P=0.002), age >70 years (P=0.041), and poor ventricular function (P<0.001). However, by use of a multivariate model, only poor ventricular function remained significant (P=0.01)., Conclusions: AF does not affect early outcome or durability of mitral repair. The onset of AF may be indicative of disease progression because of its association with poor left ventricular function.

This prospective study evaluated the clinical performance of a novel stentless quadrileaflet bovine pericardial mitral valve implanted at one center since December 1996. After giving informed consent, patients were included in the study if they required isolated mitral valve replacement. All underwent comprehensive clinical evaluation, as well as transthoracic M-mode, two-dimensional and Doppler (pulsed, continuous, and color) echocardiography preoperatively and postoperatively at 1 month, 3 months, and annually thereafter. Mitral valve area was derived by planimetry, the pressure half-time method, and the continuity equation. The degree of mitral regurgitation was semi-quantitated using color Doppler. In all 38 patients with rheumatic valvular heart disease (mean age 35+/-13 years) were monitored for 13.8+/-7.5 months (range, 1 to 29 months). All but three patients are alive and symptomatically improved (functional New York Heart Association class I or II). One valve was explanted because of early prosthetic valve endocarditis. There were no episodes of thromboembolism or anticoagulation-related hemorrhage. Left ventricular function was maintained with increased cardiac output and low transmitral pressure gradients. The mitral valve area was larger when measured by pressure half-time and planimetry than by the continuity equation (P<.05). In an independent clinical evaluation of a subset of 30 patients, mitral stenosis was considered absent in 33%, mild in 30%, mild to moderate in 26%, and moderate in 10% of cases. No or less than or equal to mild mitral regurgitation was noted in the majority of patients postoperatively, both clinically and echocardiographically. We are encouraged by the clinical performance of the quadrileaflet mitral valve and with patient outcome. Long-term follow-up data are needed to assess durability.

The title invites a discussion of a patient (age, lesion, physical condition, compliance, and other organ pathology) with aortic valve disease in the context of proposed surgical management. It further seeks clarification on the timing of such surgical contribution and on which operation is optimal. Without reviewing all the vast and somewhat conflicting literature, these aspects are addressed by a clinical cardiologist based principally on his own experience. Among the principal conclusions are the following: a) Surgery can safely be delayed in hemodynamically significant congenital aortic stenosis in children or young adults provided that the patients are nearly asymptomatic and that submaximal or maximal stress testing shows minimal or no ST-T changes. b) Prognosis after successful valve surgery for critically tight aortic stenosis in middle-aged and elderly patients differs from that for aortic regurgitation in that left ventricular myocardial dysfunction, however severe, will always improve postoperatively in the former condition. There is, therefore, never a cardiac contraindication to surgical management of symptomatic patients with tight aortic stenosis. c) Certain features in cases of chronic severe aortic regurgitation, such as diminished ejection fraction, increased end-systolic left ventricular diameter, electrocardiographic repolarization abnormalities, marked cardiomegaly on radiologic examination, and NYHA class III or IV symptoms, reflect a higher operative mortality and poorer long-term prognosis. Nevertheless, none of these features, alone or combined, can to date justify a definite contraindication to surgery in a specific patient. d) There is little uniformity or agreement among surgeons, including their cardiologists if or when that is pertinent, on the type of operation for patients of any age requiring aortic valve surgery. For example, a patient aged 40 years and depending on the "whims and fancies" of a Department or indeed those of an individual surgeon, which include his own judgement of his technical ability, may be subjected to a repair, a Ross procedure, insertion of a homograft or replacement with one of a variety of bioprosthetic and mechanical valves. The reasons, logic or motives behind these different choices are sometimes difficult, certainly for this author, to comprehend. Hopefully, ongoing international experience and research endeavors will, at least partially, clarify the current confusion. There is presumably an "optimal" way to hold a golf club or to kick a football?! The skill and judgement of the operators will, inevitably and sometimes regrettably, always vary.

The respective roles of cardiologist and cardiac surgeon in the operative management of any specific case of mitral valve disease are variable. The range from the prevalent complete predominance of the surgeon through meaningful interaction between the two, concerning the timing and type of surgery, to predominance of the cardiologist when the surgeon accepts a role of technician. There are a number of scenarios in mitral valve surgery in which a reduced risk of postoperative hospital mortality and morbidity, by performing the simplest and shortest procedure, have to be balanced against enhanced peri-operative problems when other aspects are addressed that improve, sometimes markedly, the long-term prognosis. It is argued that a mildly stenotic aortic valve should often be replaced at the time of mitral valve surgery; that despite technical difficulties and a variable long-term postoperative course, surgeons should continue to repair rather than replace the mitral valves of young patients with severe mitral regurgitation despite the invariable presence of active rheumatic carditis; and that excess leaflet tissue and lax chordae in cases of degenerative mitral regurgitation are casually related to multifocal and potentially fatal ventricular ectopy. The crucial but neglected role of an organically abnormal tricuspid anulus in allowing dilatation and hence tricuspid regurgitation in patients with rheumatic mitral valve disease is considered in some detail. Such dilatation may occur late after mitral valve surgery for rheumatic disease, has generally and incorrectly been regarded as "functional" tricuspid regurgitation, contributes importantly to the postoperative "restriction-dilatation syndrome" and can be effectively prevented, or when once established then surgically managed, by a modified De Vega anuloplasty. Finally it is believed that, unlike mitral balloon valvuloplasty in selected instances, successful tricuspid balloon valvuloplasty can never be accomplished without causing significant tricuspid regurgitation and the procedure should be abandoned.

Objective: To describe the demographic, pathologic, and hemodynamic profiles of patients with severe rheumatic mitral valve disease in a developing country and to assess their relation to uncontrolled rheumatic disease activity., Design: Retrospective, cross-sectional, cohort study., Setting: Tertiary medical center in Soweto, South Africa., Patients: 714 of 737 consecutive black patients, 4 to 73 years old, with pure mitral regurgitation, pure mitral stenosis, or mixed mitral disease who had mitral valve surgery and in whom preoperative and surgical data were concordant., Measurements: Valve lesions were evaluated on the basis of clinical, echocardiographic, hemodynamic, and surgical pathologic data. Active rheumatic carditis was diagnosed according to clinical evidence for concurrent acute rheumatic fever (Jones criteria), macroscopic appearances at surgery, and histologic findings., Results: 219 patients had pure mitral regurgitation, 275 had pure mitral stenosis, and 220 had mixed lesions. Ongoing rheumatic activity was diagnosed in 106 patients with pure regurgitation (47%) and in only 5 patients with pure stenosis (2%). Pure regurgitation was the most common lesion in the first and second decades; the relative prevalence of pure stenosis increased with age. Purely regurgitant valves had pliable, unscarred leaflets (95%), dilated mitral annuli (95%), elongated chordae tendineae (92%), and anterior leaflet prolapse (81%). In contrast, purely stenotic valves had fused leaflet commissures (100%) and rigid leaflets (38%) but no evidence of prolapse., Conclusions: The spectrum of rheumatic mitral valve disease that is hemodynamically severe in developing countries differs from that currently reported in the United States. Severe, pure rheumatic mitral regurgitation is as prevalent as pure stenosis but has an entirely different time course, surgical anatomy, and relation to disease activity, suggesting a separate pathophysiologic mechanism.

Three decades after it was demonstrated that nonejection systolic clicks and late systolic murmurs have a mitral valve origin and that a specific syndrome is associated with the primary degenerative mitral lesion, numerous questions remain unanswered. A principal cause of confusion is the use of the term 'prolapse', which essentially implies a pathological state, in many patients with minimal evidence of a mitral valve anomaly. It should be recognised that no specific feature, whether evaluated by high standard echocardiography or indeed by careful morphological and histological examination, can be defined which distinguishes a normal variant from a pathological valve. There is a gradation from the normal billowing during ventricular systole of mitral leaflet bodies to marked billowing. With advanced billowing or floppy leaflets, failure of leaflet edge apposition supervenes (true prolapse). This is functionally abnormal and allows mitral regurgitation. Prolapse in turn may progress to a flail leaflet and hence gross regurgitation. Relatively rare complications of this degenerative mitral valve anomaly include systemic emboli, infective endocarditis, arrhythmias and, arguably, autonomic nervous system abnormalities. An attempt is made to clarify the management of some symptoms and other aspects of mitral prolapse-including rheumatic anterior leaflet prolapse (without billowing) which remains prevalent in South Africa and Third World countries.

Routine stress electrocardiography has been criticised for yielding too many so-called 'false-positive' results because ST/T changes that develop during and after exercise are prevalent. Recent studies in our institution indicate, however, that the time-course behaviour patterns of these ST/T configurational 'abnormalities' after exercise are different from those reflecting myocardial ischaemia due to epicardial coronary artery disease (CAD). Time-course analysis increases the predictive value of exercise testing and has dramatically decreased the number of asymptomatic subjects or symptomatic patients at low risk of having CAD being subjected to coronary arteriography in our institution. Our method of assessing post-exercise time course patterns of abnormal ST/T are described in detail. Ischaemic ST/T abnormalities have late onset, early offset or early onset, late offset whereas those ST/T changes associated with normal epicardial coronary arteries have late onset, late offset or early onset, early offset post-exercise time course patterns.

Fulminating active rheumatic carditis has been observed for over 3 decades in this environment with no recent alteration in either the incidence or the pattern of presentation. Patients are black, seldom older than 20 years and are usually in their early teens but may occasionally be as young as five years. Heart failure is prevalent but occurs only when a haemodynamically important left-sided valve lesion supervenes. Regurgitation is the predominant valve lesion and involves principally the mitral valve. Mitral annular dilatation is the initial pathology and predisposes to lengthening--or rupture--of chordae tendineae and prolapse of the anterior leaflet. The resultant cardiac work-overload apparently perpetuates the rheumatic activity. Heart failure, whether caused by or associated with active rheumatic carditis, makes surgical management of the valve lesion mandatory as a life-saving measure. Mitral valve repair, rather than replacement, is the surgical procedure of choice but is not always practicable when the rheumatic activity is fulminant, significant aortic regurgitation associated or the surgeon relatively inexperienced. Aggressive medical therapy for heart failure, which should include vasodilator drugs, provides temporary improvement only. Contrary to ongoing doctrine, treatment with steroid drugs is neither life-saving nor beneficial. Varying degrees of left ventricular dysfunction are encountered pre-operatively and may be a sequel of the severe regurgitant valve lesion rather than of a rheumatic 'myocardial factor'.

Flight surgeons recognize that ongoing vigilance is necessary to detect coronary artery disease (CAD) in aircrew. Regular physical examinations with only a resting electrocardiogram, albeit having a very low predictive value for detection of CAD in asymptomatic subjects, are now widely practised. Routine stress electrocardiography has been criticized for yielding too many so-called "false positive" results because ST/T changes that develop during and after exercise are prevalent. Recent studies in our institution indicate, however, that the time-course behavior patterns of these ST/T configurational "abnormalities" after exercise are different from those reflecting myocardial ischemia due to epicardial CAD. Time-course analysis increases the predictive value of exercise testing and has dramatically decreased the number of asymptomatic aircrew being subjected to coronary arteriography in our institution. Routine exercise electrocardiography provides a reliable, cost-effective means of detecting aircrew with CAD and a baseline for comparison at subsequent examination, and we strongly recommend that it be universally reinstated.

Routine exercise electrocardiography has been criticized for yielding too many so-called "false-positive" results. Recent studies in our institution indicate that evaluation of the time course behavior of ST segment and T wave (ST/T) changes after cessation of exercise differentiates ischemic from non-ischemic ("false-positive") stress electrocardiograms (SEs). Our method of assessing time course behavior is clarified. The principal aim of this study was to determine the accuracy of experienced observers in making this differentiation. Records of consecutive patients undergoing coronary arteriography over a 2 year period were reviewed and 30 with SEs judged positive for ischemia by the widely accepted ST/T configurational criteria alone were selected at random for the investigation. Sixteen subjects had normal coronary angiograms and had therefore previously been regarded as having false-positive SEs. Fourteen patients had at least one significantly (> 70%) stenosed coronary artery which was our yardstick for ruling that true myocardial ischemia, due to epicardial coronary artery disease (CAD), was present. Five observers, familiar with post-exercise ST/T time course patterns, independently and "blindly" analyzed all 30 configurationally abnormal SEs. Observers were informed only of the patient's age and sex; they were thus unaware of symptoms, exercise variables, coronary anatomy and the number of patients in the 2 groups. The observer consensus for ischemia of SEs using time course analysis was: total test accuracy 87%, sensitivity 79%, specificity 94%, positive predictive value 92% and negative predictive value 83%. Because all 30 patients had ST/T abnormalities, results of the sample for ischemia based on configurational criteria alone were sensitivity 100%, specificity 0% and positive predictive value 47%. We concluded that time course analysis plays a crucial role in evaluating SEs and that exercise electrocardiography remains a safe, cost-effective and reliable method of screening many asymptomatic, as well as symptomatic, subjects for CAD.

Routine stress ECG has been criticised for yielding too many so-called false-positive results because ST-segment and T-wave (ST/T) changes that develop during and after exercise are prevalent. Recent studies in our institutions indicate that the time-course behaviour patterns of ST/T configurational abnormalities after exercise reflecting myocardial ischaemia are different from those that do not. The epicardial coronary arteries of 111 patients, who had positive stress tests for ischaemia based on ST/T configurational changes alone but were considered non-ischaemic when the ST/T time-course behaviour was analysed, were assessed. Of these patients, 102 had normal coronary arteries, 7 had insignificant stenoses and only 2 had significant coronary artery diseases. ST/T abnormalities on stress testing with a non-ischaemic time-course pattern should be regarded in the same category as ST segments that remain normal as far as the detection of myocardial ischaemia due to epicardial coronary artery disease is concerned. This policy has resulted in an improved predictive value of exercise testing and has considerably decreased the number of patients subjected to coronary arteriography in our institutions. The assessment of the post-exercise stress ECG remains the most practical and cost-effective method for detecting ischaemic heart disease.

Fulminating active rheumatic carditis has been observed for over three decades in this environment with no recent alteration in either the incidence or the pattern of presentation. Heart failure (in this context defined as 'an inadequate circulation at rest together with a raised pulmonary venous pressure, with or without an associated high systemic venous pressure in the absence of haemodynamically significant tricuspid valve disease or pericardial effusion') is prevalent but occurs only when a haemodynamically important left-sided valve lesion supervenes. Regurgitation is the predominant valve lesion and involves principally the mitral valve. Mitral annular dilatation is marked and predisposes to lengthening--or rupture--of chordae tendineae and prolapse of the anterior leaflet. The resultant cardiac work-overload apparently perpetuates or aggravates the rheumatic activity. Heart failure, as defined, whether caused by or associated with active rheumatic carditis, makes surgical management of the valve lesion mandatory as a life-saving measure. Aggressive medical therapy for heart failure, which should include vasodilator drugs and especially angiotensin-converting enzyme inhibitors, provides temporary improvement only. Contrary to ongoing doctrine, treatment with steroid drugs in this context is neither life-saving nor beneficial.

The mechanism of severe mitral regurgitation (MR) due to active rheumatic carditis is ill defined. This study involved 73 patients, aged 7 to 27 years (mean 13), with severe MR and active rheumatic carditis who were subjected to surgery. Sixty-one were studied retrospectively (group 1) and 12 prospectively (group 2). Active rheumatic carditis was diagnosed according to the modified Jones' criteria, morphologic appearances of the heart at operation and histology of the valve. All patients had preoperative 2-dimensional echocardiographic and intraoperative assessment of the mitral valve apparatus. The presence of mitral valve prolapse--defined as failure of leaflet edge coaptation resulting in systolic displacement of the free edge of the involved leaflet toward the left atrium--was determined in all patients. Mitral anular diameter and maximal systolic chordal length were measured at 2-dimensional echocardiography in group 2 patients and compared to values obtained from matched control subjects. Anular and chordal dimensions in 6 of the group 2 patients were correlated with precise measurements obtained at surgery. Mitral valve prolapse involving the anterior leaflet was detected on echocardiography and confirmed at surgery in 69 patients (94%). Mitral anular dilatation was observed at operation in 70 patients (96%). Maximal anular diameter was significantly greater (p less than 0.0001) than in matched control subjects (37 +/- 4 vs 23 +/- 2 mm). The mean anular dimension measured at surgery (36 +/- 3 mm) was similar to that obtained by echocardiography and individual values using the 2 methods correlated well (r = 0.93). Chordal elongation was observed in 66 patients at operation (90%).(ABSTRACT TRUNCATED AT 250 WORDS)

In 1972 we conducted a survey of 12,050 urban Black schoolchildren and detected 168 (prevalence rate of 14 per 1,000) with a non-ejection systolic click (NESC), a late systolic murmur, or both. The etiology of the mitral valve abnormality was unknown but we considered that a significant proportion might have early rheumatic heart disease. The auscultatory features four years later of 139 of the original 168 subjects as well as those of 139 age- and sex-matched controls are presented in this study. No cardiac abnormality was detected in as many as 55 of the subjects. Five children now had pansystolic murmurs but the mitral regurgitation was assessed as mild in four. Twenty-five (17.9 per cent) of the controls, 23 of whom had NESCs, had auscultatory features compatible with mitral valve prolapse. These findings do not support our earlier suggestion that a large number of the 1972 subjects have mild rheumatic heart disease. The results are in accord with other studies which have indicated that auscultatory features compatible with mitral valve prolapse are common in "normals" and also that the prognosis of the specific "billowing mitral leaflet syndrome" is generally benign.

Mitral valve aneurysm is an uncommon complication of infective endocarditis. This report describes a patient with severe regurgitation due to perforations in a mitral aneurysm who required mitral valve replacement 9 years after a staphylococcal infection was superimposed on a billowing mitral leaflet. The unusual auscultatory signs and angiographic appearance could have led to diagnosis of the aneurysm.

Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.

A patient is described in whom an aneurysm of the posterior mitral leaflet caused severe mitral incompetence and cardiac failure. The aneurysm was seen as an additional echo-free space within the left atrium in the real time two dimensional echocardiogram. Both echocardiographic and cineangiocardiographic appearances were misinterpreted initially because the aneurysmal leaflet did not more into the left ventricle during diastole. This feature was explained during the successful surgical repair of the valve by the observation that the aneurysm was adherent to the left atrial wall.

Aortocaval fistulisation is a rare condition which results in a high mortality rate if misdiagnosed before surgery. The presentation can be either acute or insidious. The paucity of definitive clinical symptoms, the haemodynamic consequences of a large arteriovenous fistula and the technical difficulties of surgery all contribute to this high mortality rate. We describe 6 patients whose case histories illustrate these points and discuss the management of patients with aortocaval fistulas.