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A 50-year-old black man presented at the emergency department with midsternal, nonradiating chest pressure and chronic dyspnea on exertion. Four years before the current admission, he had been diagnosed with nonischemic cardiomyopathy at another facility. After our complete evaluation, we suspected that his symptoms arose from left-to-left shunting in association with pulmonary sequestration, a congenital malformation. Our preliminary diagnosis of secondary dilated cardiomyopathy was confirmed by normalization of the patient's ventricular size and function after lobectomy. To our knowledge, this patient is the oldest on record to present with cardiomyopathy consequent to pulmonary sequestration. His case is highly unusual because of his age and the rapid resolution of his symptoms after lobectomy. We believe that pulmonary sequestration should be included in the differential diagnosis of dilated cardiomyopathy.

Paraplegia developed in a 70-year-old man after resection of a ruptured abdominal aortic aneurysm during which aortic occlusion time was 45 minutes. Between one and three months postoperatively, he progressively recovered motor function to the point where he could walk unaided. Only four patients have previously been reported to recover from paraplegia produced in this manner. A review of the literature on the anatomy of the arterial supply to the spinal cord indicates the importance of the anterior spinal artery and the artery of Adamkiewicz (arteria magna radicularis). Paraplegia is more common in patients with hypotension and when backbleeding from the lumbar arteries has been poor.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare and usually fatal congenital malformation. Most surgical attempts to correct this anomaly have been unsuccessful, particularly those in infants. Recently, four patients underwent reimplantation of an anomalous left coronary artery into the aorta; all four survived the operation and are asymptomatic. This technique of reimplantation of the aberrant vessel into the aorta appears to be prefereble to other methods of repair, especially since it can be applied in any patient with the anomaly regardless of age or size. Because of the poor prognosis for patients with anomalous left coronary artery, surgical intervention should be made as soon as the diagnosis is made.

The treatment of 54 patients with pancreatic pseudocysts was reviewed. The operative mortality was 11% and after an average followup of 3 years the recurrence rate was 3.8%. Hemorrhage was the most significant complication of pseudocysts and occurred in 4 patients preoperatively and three patients postoperatively. The patients who developed recurrence or died had been operated within one day after the diagnoses of pseudocysts were made. The deaths were due to the conditions that necessitated the emergency operations rather than to the fact that the cyst wall had not adequately matured. Ideally, operation should be performed when the patient has reached an optimal clinical condition and the walls of the cyst are sufficiently thick. Currently there is no guide for estimation of the state of cyst maturation, although this may develop with the use of ultrasound. Since complications can develop during a prolonged observation period it was our policy to proceed with surgery as soon after diagnosis as the patient was in satisfactory clinical condition. It is evident from this study that internal drainage can be performed safely in less time than the 6 weeks frequently recommended. Morbidity and mortality were not adversely affected by a short interval between diagnosis and operation if the timing was a matter of election rather than a condition of emergency.