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We report a 72-year-old woman with severe congenital stenosis of the left coronary artery orifice and clinically significant atherosclerotic changes in both the right and left coronary arteries. The stenotic ostium was located at the point at which the left and posterior aortic valve leaflets joined to form the left commissure, just at the distal vertex of the left interleaflet triangle, between the left and posterior aortic sinuses. The right coronary artery was more developed in size than usual, whereas the left coronary artery consisted of a short left main coronary trunk that bifurcated into left anterior descending and left circumflex arteries. The left coronary artery system was filled retrogradely through two vessels proceeding from the right coronary artery, namely, the conal artery and a well-developed branch that ran across the interventricular septum. This abnormal arrangement of the coronary arteries showed striking functional similarities with atresia of the left main coronary artery. Current knowledge on the morphogenesis of the coronary arteries suggests that the present anomalous coronary artery pattern resulted from the penetration of the anticipated left coronary artery system into the aorta at a totally erroneus site. This hindered the normal development of the ostium, which subsisted as a punctiform, practically nonfunctional opening.

Among the 1,993 patients undergoing open-heart operations, our incidence rate of mediastinitis was 0.6%. Six patients have been treated with the pedicled omentum. Two of the 6 patients had a valvular disease and a coronary bypass the others. All patients had a good result with this procedure. After this experience, we think it is the best technique for management of this major complication.

We present 4 cases of dissection of the coronary arteries during coronary radiography, which required emergency surgery. The right coronary was dissected in 2 cases and the left coronary in the remaining cases. Coronary artery bypass was carried out using saphenous vein. Although one patient suffered myocardial infarction, all patients had successful recovery and evolution.

We present four cases of late thrombotic obstruction of the Björk-Shiley aortic valve prosthesis. The incidence of this complication reported in the literature to vary from 0.7% to 5%. In our experience of a total of 623 Björk-Shiley aortic valve replacements, we observed this complication in only 4 patients (0.6%). Two of them had poorly controlled anticoagulation therapy. The clinical presentation was subacute in all four patients. Surgical treatment, thrombectomy and debridement, was performed in all of them. The diagnosis was made upon abrupt and progressive onset of dyspnoea, physical examination data and echocardiographic and radioscopic findings. Angiocardiographic studies were needed in two patients.

The case of a patient undergoing an emergency aortocoronary bypass to the right coronary artery after its acute dissection at coronariography is presented. Surgery was carried out two hours after the incident. After successful recovery and postoperative study, it was concluded that the main technical problem posed by this operation which was whether or not to ligate proximally the right coronary was satisfactorily solved by the initial decision not to ligate it.

Three patients presented subacute right heart failure, 6, 12 and 22 months after replacement of the tricuspid valve with a Björk-Shiley prosthesis. The principal finding encountered on clinical examination was a tricuspid filling murmur with inspiratory accentuation. The mean prosthetic gradient found at cardiac catheterization was 7, 8 and 10 mm Hg. At surgery, the three prostheses were thrombosed on their ventricular aspect and all the three were replaced with new ones of the same model. The patients are alive and in good condition, 21, 17 and 8 months after the operation. Problems which relate to the surgical management of tricuspid valve disease are discussed.

A new technique of circular tricuspid annuloplasty in the treatment of tricuspid insufficiency is described. One hundred and fifty patients have been operated on by this technique between April 1973 and March 1975. The operative findings and the results of the operation from 6 to 30 months after operation are described. The addition of tricuspid circular annuloplasty to mitral and aortic valve replacements where indicated has resulted in a gratifying fall in operative mortality and better long term functional result.

Apicoaortic conduit implantation is easier and safer with cardiopulmonary bypass. We present an analysis of two cases in which the operation was successfully concluded without the bypass. The first patient had a simultaneous correction of aortic coarctation and tunnelliform subaortic stenosis 8 years ago and is asymptomatic at present. The second patient suffered from hyperlipoproteinemia, calcification of the ascending aorta and femoral arteries and severe aortic stenosis. One month after surgery be suffered cardiac arrhythmia and died. Although this experience is limited, we believe that information about this alternative method may be useful in some cases.