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A 75-year-old woman with familial hypercholesterolemia was admitted with unstable angina. Thirteen years earlier, she had undergone coronary artery bypass grafting with a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and subsequently bilateral common carotid bypass surgery through a second sternotomy 3 years later. Physical examination revealed left brachial hypotension, a left subclavian bruit, and features of severe aortic stenosis. Transthoracic echocardiography demonstrated severe valvular and supravalvular aortic obstruction with an area of 0.50 cm2. Noncontrast computed tomography showed complete calcification of the ascending aorta (porcelain aorta) and confirmed supravalvular obstruction with calcific plaque (Figure 1). She was subsequently offered placement of a left ventricular apex-descending aorta conduit through a left thoracotomy. Preoperative diagnostic angiography revealed a critical ostial left subclavian artery stenosis, with flow reversal in the vertebral artery and preferential entering of contrast into the LIMA (steal phenomenon, Figure 2, Movie 1). The LIMA graft was widely …

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 71-year-old man with a history of coronary artery bypass grafting 10 years earlier presented with recurrent angina. A repeat coronary angiogram revealed a large pseudoaneurysm in the saphenous vein graft supplying the right

Cleft mitral valve is a rare congenital anomaly that may present in isolation or accompany other cardiac malformations. Our illustrative case series highlights the advantages of three-dimensional over conventional two-dimensional echocardiography in the diagnosis and morphologic assessment cleft mitral valve in adults.

Quadricuspid aortic valve is a rare congenital anomaly. It may present as an isolated anomaly but is occasionally associated with aortic regurgitation. Sinus of Valsalva aneurysm (SVA) is also an infrequent congenital anomaly, typically associated with tricuspid aortic valves. There are only a few reported cases of SVA (ruptured) associated with quadricuspid aortic valves in the literature. We report the first case of the association of quadricuspid aortic valve with an unruptured SVA in an adult patient.

Brain natriuretic peptide (BNP) level is elevated in heart failure and reflects its severity. It is unknown why some patients have extremely high BNP levels. The authors retrospectively reviewed data on 179 consecutive patients whose BNP levels fell within one of several predetermined ranges: mild elevation, 500 to 1000 pg/mL (n=82); moderate elevation, 2000 to 3000 pg/mL (n=48); and high elevation, 4000 to 20,000 pg/mL (n=49). The statistical analysis was conducted with the unpaired t test and Pearson's correlation coefficient. Adjustments were made for age, sex, and serum creatinine level. Patients with moderate BNP elevation were more symptomatic and had more advanced structural and hemodynamic changes than did patients with lower BNP elevation. Characteristics of the high BNP level group did not differ from those of the moderate BNP level group. Serum creatinine level correlated with BNP level, but neither age nor sex did. High BNP level (4000-20,000 pg/mL) is determined more by renal dysfunction than by the severity of heart failure.

Melanoma is a neoplasm notorious for its dismal prognosis and its propensity for cardiac involvement. Roughly a third of patients diagnosed with primary cutaneous melanoma develop pulmonary, osseous, cerebral or hepatic metastatic disease ante mortem. In contrast, ante mortem cardiac involvement is reported in 2% of cases but in over 50% of patients with metastatic melanoma postmortem.1 Cardiac involvement is usually multifocal, believed to disseminate hematogenously and commonly involves the epicardium, myocardium, pericardium or may present as intracavitary tumors.2 The surgical management of cardiac tumors can be challenging, particularly when they occur in locations that make surgical access and resection technically difficult. Recent refinements in myocardial perfusion imaging, computerized tomography, and cardiac magnetic resonance imaging help provide precise information on anatomic location, vascularity, and tumor extension into adjacent mediastinal structures.3 Early detection of cardiac melanoma has important therapeutic and prognostic …

The study was conducted to identify epidemiological sero-distribution of Leptospira serovars representing serogroups of antibodies in Odisha, Eastern part of India. Samples were collected from livestock during 2011-2014. A total of 537 non-purposive random serum samples from 12 districts in Odisha were tested at 1:100 dilutions in microscopic agglutination test (MAT) using live antigens of 18 reference Leptospira serovars. The overall prevalence of 36.69% (197/537) with 36.13% in cattle, 54.28% in buffaloes, 28.33% in goats and 44.44% in sheep was observed. Out of 197 reacted sera, 100 samples showed reactivity with more than one serovars representing 50.76% prevalence of multiple serovars. On analysis, the seroprevalence of leptospirosis in cattle (·2 = 63.41, P