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Clinical and cardiac catheterization data were collected from 39 infants with coarctation of the aorta and ventricular septal defect, 31 of whom were initially managed only by surgical repair of coarctation. Data were analyzed to determine mortality, morbidity, outcome and factors that might predict survival or the need for septal defect closure.Of the eight patients who did not require surgical treatment before 3 months of age, seven underwent coarctation repair alone at a mean age of 2.3 years. Of the 23 infants managed with coarctation repair alone, before age 3 months, 9 needed no additional surgical treatment and 6 required early and 8 required late repair of the ventricular septal defect. Seven infants underwent coarctation repair and simultaneous pulmonary artery bandnig and one eventually required debanding after spontaneous closure of the septal defect. The overall mortality rate in this series was 10.3% (mean follow-up time 5.7 years). Of 39 infants, 16 (41%) never required a second operation for ventricular septal defect closure.For patients who had only coarclation or coarctation repair with pulmonary artery banding at 1 cm/m2) on the basis of defect size at operative repair or echocardiographic or angiographic assessment. Defect size did not necessarily correlate with the need for operative repair. Stepwise multiple regression analysis revealed that increased right to left ventricular peak systolic pressure (p = 0.004) and decreased systemic venous oxygen content (p = 0.028) were significantly predictive of the eventual need for ventricular septal defect repair.Thus, most infants with coarctation of the aorta and ventricular septal defect do not require pulmonary artery banding or open heart closure of the ventricular septal defect at the time of coarctation repair. A significant number of infants will not require a second operation.

Developmental abnormalities in the systemic blood supply to the lungs occur in association with congenital heart disease, congenital lung disease, and rarely with apparently normal heart and lungs. Although most of these anomalies are rare, in the aggregate they are relatively common and of special interest to students of chest and heart disease.

Indices based on early systolic ejection rates are theoretically more sensitive to ventricular performance than indices based on the entire systolic ejection (SE) period (mean ejection phase indices-MEPI): mean systolic ejection rate (MSER), mean normalized systolic ejection rate (MNSER) and mean velocity of circumferential fiber shortening (MVcf). The volume ejected in early systole is an indicator of the early rate of ejection. Accordingly, ventricular volume changes were determined by ventriculographic analysis for each thrid of SE in ml/sec (SER), as normalized systolic ejection rate (NSER), and as percent of stroke volume (PSV). In ten normal controls all these indices were higher in the first third compared to the other thirds of SE. Seven patients with diffuse ventricular disease had depressed values in the first third of SE. Despite "normal ventriculograms and normal MEPI, eight patients with left anterior descending coronary artery stenoses (greater than 60%) also had definitely depressed ejection indices during first third of systole. Detailed wall motion analysis in this group showed anteroapical hypokinesis isolated to the first third of SE. These data show that indices based on early SER are more sensitive than MEPI (MVcf, MNSER) for detecting abnormalities in ventricular performance in coronary artery disease

Infants with pulmonary atresia and intact ventricular septum (PA-IVS) usually require urgent surgical intervention. Thirty patients with this anomaly, seen at the Columbia-Presbyterian Medical Center between 1962 and 1978, had palliative operations, 26 within the first 3 days of life. Six underwent a closed pulmonary valvotomy alone, with no survivors; six had only a systemic–pulmonary artery shunt, with three early survivors. Because of this experience, 17 had a combined procedure of valvotomy and shunt, with 14 early survivors. One patient recently underwent a definitive right ventricular outflow patch procedure with cardiopulmonary bypass. Eight patients subsequently have had corrective open-heart procedures, with five patients surviving from 2 to 10 years. A unicusp aortic homograft was used for repair in five and a Hancock valved conduit in three. Four patients are presently awaiting operation. We conclude that the initial surgical management of these critically ill infants must not only increase pulmonary blood flow but in addition provide an opportunity for right ventricular growth. Thus we continue to advocate the combined procedure of a valvotomy plus a shunt to provide adequate palliation. Repeat catheterization should be performed within a year to confirm the adequacy of the valvotomy, since this is essential to maximal right ventricular enlargement and to allow for definitive correction at a later date.

Persistence of the fetal circulation is a recently recognized cause of severe cyanosis in newborn full term infants. Abnormally elevated pulmonary vascular resistance apparently stimulated by hypoxia, acidosis, and/or hyperviscosity results in cyanosis due to large right-to-left shunts through persistent fetal channels (patent foramen ovale and patent ductus arteriosus). Initial chest radiographs demonstrate clear lungs, decreased, normal, or mildly prominent pulmonary vascularity, and normal to moderately enlarged cardiac silhouettes. Angiocardiography, when required to rule out cyanotic congenital heart disease, demonstrates normal intracardiac anatomy, normal great vessel relationships, and right-to-left shunting across the patent foramen ovale and patent ductus arteriosus. Significant tricuspid regurgitation occurs in some of these infants, associated with variable right ventricular dilatation; the left ventricle is normal. The majority of babies with this condition ultimately survive. Treatment consists of intensive care including oxygen therapy and correction of acidosis. Vasodilators such as tolazoline may be helpful.

Reports of 4 adults with impressive superior mediastinal masses secondary to tuberculous lymphadenitis are briefly presented. Three of the four were young adults, 25 or 26 years old.All presented with nonspecific clinical symptoms. One patient, however, had a large supraclavicular lymph node mass. All had 4+ positive intermediate strength PPD reactions. One developed polyserositis with large pleural and pericardial effusions. All responded well to antituberculous chemotherapy after the diagnosis was suggested by cervical lymph node biopsy or mediastinoscopic lymph node biopsy (in 1 case).The differential diagnosis includes mainly lymphoma, substernal thyroid, thymoma, teratoma and other granulomas, including sarcoid, and fungal infections.It is important for the radiologist to suggest the possibility of tuberculosis as a cause of a superior mediastinal mass, particularly in the young adult, even though no hilar lymphadenopathy on pulmonary densities are evident.The diagnosis of tuberculous lymphadenitis c...

The "shock lung syndrome," whenever associated with trauma, is probably in part the consequence of fat emboli, though aspiration, disseminated intravascular coagulation, microatelectasis, pulmonary edema, and hemorrhage due to other lung insults may be important in the etiology of many cases. When lung injury is due to fat emboli, there is an interval between the time of trauma and the onset of clinical symptoms and chest radiographic findings. The radiographic picture is that of a diffuse alveolar and interstitial lung density. In severe cases marked respiratory embarrassment requires the use of both oxygen therapy and mechanical respirators for survival.

A remarkable patient is described, a child who has survived until the age of 7 years with hypoplastic left heart syndrome (mitral and aortic atresia) without surgical intervention. The child has led an active, normal life and, aside from minimal cyanosis, has remained asymptomatic. The unique clinical course for this patient is the result of a number of favorable hemodynamic factors that have not been previously reported in an individual patient with hypoplastic left heart syndrome and intact ventricular septum: 1) widely patent ductus arteriosus, 2) adequate retrograde coronary flow, 3) unrestricted pulmonary venous return, and 4) absence of significant vascular obstructive disease. This documentation of longterm survival in a child without surgical treatment for mitral and aortic atresia suggests that successful early palliative treatment for infants with this syndrome could also result in a favorable prognosis.

The clinical, hemodynamic, and angiographic observations, as well as the surgical approach used for repair in three patients with congenitally corrected transposition of the great arteries and ventricular membranous septal aneurysms, are presented. In two of the three patients the membranous septal aneurysm caused subpulmonary obstruction, with 94 and 125 mm Hg systolic gradients. In each patient the aneurysm was demonstrated by angiocardiography, which also showed differences in size and shape with cardiac systole and diastole. Review of the previously described reports indicates that patients with congenitally corrected transposition often display various forms of pulmonary outflow obstruction and when a ventricular membranous septal aneurysm exists, a significant subpulmonary obstruction is present in most patients. The unique anatomic relationship between the pulmonary artery and a ventricular membranous septal aneurysm in patients with transposition of the great arteries with and without atrioventricular discordance explains why subpulmonary obstruction sometimes develops.

Congenitally corrected transposition of the great vessels is an important basic anomaly of the heart which has only recently received wide clinical attention. First described by von Rokitansky in 1875 (33), the anomaly remained a clinical curiosity until modern surgical advances in the treatment of congenital heart disease made accurate diagnosis important. Less than 150 cases are described in the literature, but the condition cannot be extremely rare, since we have encountered more than 30 cases, and similar large series have been reported from other institutions (17, 27). Among our cases is the first example of congenitally corrected transposition without associated anomalies diagnosed on the basis of chest films, the second such case to be recognized in life. Basic Anatomy of Corrected Transposition of the Great Vessels The aorta and pulmonary artery are transposed so that the aorta arises on the left and ventrad, in the usual position of the pulmonary artery, while that vessel arises on the right and ...

Forty-one consecutive patients, ranging in age from 41/2 to 27 years, were operated upon for complete repair of tetralogy of Fallot without an operative mortality. Postoperative catheterization of 25 patients permitted objective evaluation of the results which were, by the criteria adopted, excellent in 16 patients, good in 5, and poor in 4, including the 2 late deaths. Surgical experience has shown the necessity for extensive resection of the right ventricular outflow tract. Prosthetic patches are considered necessary for closure of most of the ventricular septal defects encountered, but are infrequently needed for reconstruction of the right ventricular outflow tract. Its use is indicated in certain patients with hypoplasia of the pulmonary annulus or artery. Age has been an important factor in patient selection. It is suggested that symptomatic patients under five years of age may benefit from a systemic-to-pulmonary arterial anastomosis before definitive correction is undertaken later in childhood.

Postoperative cardiovascular studies were carried out in eight patients with ostium primum defect and cleft mitral valve. Apical systolic murmurs were present in all patients, but in seven of them no mitral regurgitation was detected by pulmonary wedge pressure and left ventricular angiography. Surgical repair of the cleft anterior leaflet without resection of subjacent chordae tendineae, as performed in these patients, usually results in a competent mitral valve. Postoperative angiograms showed persistence of the characteristic preoperative deformity of the medial border of the left ventricular outflow tract especially in systole. As illustrated in one of these patients, subaortic obstruction occasionally complicates abnormalities of the atrioventricular valves.

1. Babies with pulmonary atresia and intact ventricular septum rarely survive for more than a few weeks after birth. Prompt diagnosis and recent advances in surgical treatment now offer greatly improved possibilities for long term survival.2. Emergency angiocardiography is necessary for precise preoperative diagnosis.a. Venous or right atrial angiocardiograms are generally inadequate for accurate diagnosis.b. Selective right ventricular angiocardiography best shows the size and position of the right ventricle, the pulmonary valvular atresia and the intact ventricular septum, but poorly demonstrates the left heart and the lung vessels. Tricuspid atresia is ruled out.c. Selective left ventricular angiocardiography shows the left heart, aorta and pulmonary blood supply as well as the distal surface of the atretic pulmonary valve. The right coronary artery position permits an estimate of right ventricular size.d. A combination of both selective right and left ventricular angiocardiograms is ideal. Either exam...

Anatomically true cross-sectional ultrasonic images of the heart have demonstrated ventricular septal defects in 25 patients with this lesion as an isolated anomaly or in conjunction with other defects. In two additional patients a defect was visualized but confirmation was not obtained. Ventricular septal defects were not demonstrated in 13 other patients in whom this lesion was identified by other techniques. In these instances the lesion was not sought for, was inaccessible, or was too small to image. Defects were manifested by the septum overriding the posterior great artery, septal discontinuity immediately below the posterior semilunar valve, or a discontinuity caudal to the posterior semilunar valve. It appears that cardiac ultrasonography may be able to demonstrate most of the common larger ventricular septal defects occurring in the infracristal region of the septum.

1. The interatrial septum is responsive to relative changes in atrial pressures.2. Normally the septum bulges toward the right atrium which normally has a lower pressure than the left atrium.3. Most types of acquired cardiac disease relatively increase left atrial pressure, resulting in more prominent bulging of the septum toward the right atrium.4. The atrial septum may oscillate in position when interatrial pressure differential intermittently reverses direction— usually when atrial pressures are of similar magnitude, the "floppy atrial septum."5. In constrictive pericarditis the dorsal wall of the right atrium including the septum may be unusually straight.6. When the right atrial pressure is higher than that in the left atrium, the left atrium may be remarkably deformed and display a characteristic filling defect produced mainly by the bulging interatrial septum, the "crushed left atrium." The filling defect can be mistaken for a tumor mass (i.e., myxoma).7. The above alterations may be observed by an...

A three and one-half month old infant with corrected transposition of the great vessels, pulmonary atresia, and intact ventricular septum is presented. Cardiac catheterization and angiocardiography disclosed a small blind right-sided pulmonary (anatomic left) ventricle with systolic pressure exceeding systemic levels. The chamber communicates with the coronary arterial system via transmyocardial sinusoids. To our knowledge, this is the first report of this syndrome complex diagnosed during life.

This paper reports the results of a statistically controlled study of the effectiveness of two widely used drugs on radiation sickness. The drugs tested were pyridoxine, first advocated by Maxfield and his associates in 1943 (1), and Dramamine, advocated by Beeler et al. in 1949 (2). These were selected as representative of two groups of compounds commonly used in radiation sickness, namely, antimotion sedative-type drugs and vitamins. Evaluation of whether or not a patient has radiation sickness is difficult because it is largely a subjective syndrome, the symptoms of which can be caused by many different processes, organic and psychologic, that may be active in those receiving radiation therapy. In addition, it is difficult to eliminate bias on the part of both patient and doctor in assessing the response to any medication for specific complaints. In order to minimize errors due to these factors, the drugs and placebos used in this study were made up in identical appearing capsules and all patients were...

The clinical course of thirty-five patients, seventeen years of age and over, with ventricular septal defect observed during the past thirty years is reviewed. Thirty-one patients were studied by right heart catheterization since 1946; ten were recatheterized five to thirteen years after the initial investigation. The remaining four were examined at necropsy before cardiac catheterization technics were available. A wide spectrum of hemodynamic findings was noted at all ages in adult life. The two largest groups were those with normal pulmonary artery pressure (group i) and those with pulmonary artery pressure at approximately the systemic level (group iv). In the first group the patients were essentially asymptomatic and showed no change in pulmonary artery pressure with advancing age. In contrast, most of the patients with severe pulmonary hypertension were symptomatic in infancy or early childhood and probably always had elevated pulmonary artery pressure. They manifested progressive pulmonary vascular disease with the development of cyanosis and ultimately right-sided heart failure. Bacterial endocarditis was the cause of death in three of the four patients examined at necropsy before 1946. This complication was infrequent among the patients in recent years and was never a terminal event. In this series only five patients were forty years of age or over, the oldest was forty-nine years of age. The explanation for lack of patients beyond fifty years is not clear, but shortened survival time is suggested.

We have presented a brief review of some congenital anomalies of the pulmonary arterial vasculature, including aneurysms, coarctations and anomalous origins. Knowledge of these malformations is important to radiologists, since many of the surgically correctible lesions can be suspected from the plain chest roentgenograms and confirmed angiocardiographically.

Cardiac ultrasonography is a technique for producing motionless cross-sectional images of intracardiac anatomy by means of an electrocardiogram-gated ultrasonic contact scanner. Images obtained can demonstrate the normal spiral or crossed relationship of the ventricular outflow tracts and arterial trunks. In transposition of the great arteries the axes of the ventricular outflow tracts and arterial trunks are more or less parallel and the anterior aorta is placed variably to the left, anterior, or right of the posterior pulmonary trunk. One or both of these anatomic features were correctly demonstrated by cardiac ultrasonography in 14 of 16 patients with transposition of the great arteries. The technique holds promise for practical application in clinical diagnosis of congenital heart disease.

Time-of-planting experiments were conducted with potatoes on the Northern Indiana Muck Soils Experimental Farm, near Walkerton, Indiana, during the period from 1939 to 1942. Both total yields and yields of marketable or essentially scab-free potatoes, were determined for crops from plantings made at 5 two-week intervals from about the 5th of May to the 5th of July.

1. In the normal, unanesthetized rabbit, resting quietly in its normal position, catheterization of the right ventricle (and central veins) altered the distribution of blood throughout the lung in a characteristic manner. 2. Regional pulmonary vasoconstriction, rather than passive changes in vascular caliber or in the flow properties of blood, seemed to be involved. 3. The mechanism for the regional pulmonary vasoconstriction is considered in terms of a neurohumoral pathway, involving afferent pathways from the right heart, connecting channels in the upper cervical segments of the spinal cord, and release of a histamine-like substance at the neuro-vascular junctions.

Neurologic complaints, in the absence of other symptoms, may rarely characterize the presentation of a patient with chronic obstructive lung disease (1 ). Headaches, muscular twitches, visual changes, and altered levels of conscious- ness are not uncommon in severe chronic respiratory insuf- ficiency, but the patient's dominating symptoms are usually respiratory (2, 3). Recently, we evaluated a 48-year-old woman who complained only of headaches and decreased visual acuity; physical examination revealed only a few auscultatory wheezes and bilateral papilledema with hem- ornhages. After extensive neunoradiologic evaluation re- vealed an eroded, slightly enlarged, and partially empty sella tuncica, hypoxemia and hypercapnia of pulmonary emphysema were assumed to be the mechanism leading to the neurologic complaints and sellan abnormalities.

The first documentation is reported of spontaneous closure of a coronary artery to right ventricle fistula that was demonstrated initially in a 14 month old boy. Over a 4 year period after diagnosis, the characteristic continuous murmur gradually disappeared. When the patient was 5 1/2 years of age, selective coronary arteriography showed normal coronary vessels and circulation. Six other cases of coronary fistula observed during the past 10 years are also reviewed. This study supports the rationale for clinical follow-up rather than obligatory surgical intervention in asymptomatic patients with a small shunt who have no evidence of myocardial dysfunction.

Because it is impossible to measure the balance between coronary blood flow and the metabolic needs of the myocardium for oxygen by exclusively radiographic means, investigators in this laboratory developed a technique to make quantitative estimates of capillary blood flow in multiple areas of the human myocardium using 133xenon and a multiple-crystal scintillation camera (1–3). The purpose of this report is to present preliminary results of studies of 175 patients who were studied at Columbia University. The regional myocardial perfusion rates obtained with the method were correlated with radiographic assessments of the degree and the extent of the coronary disease in each patient.

Measurements of mean left ventricular (LV) and regional myocardial blood flow rates were made at rest in 161 patients with 133Xe and a multiplecrystal scintillation camera. Myocardial perfusion rates were correlated with assessments of the degree of coronary artery disease made from the arteriograms obtained during the same studies. In patients with normal coronary arteries without heart failure, the presence of hypertension, aortic stenosis, or aortic insufficiency was not associated with changes in mean LV perfusion from the control value of 61+/-7 ml/100 g-min. However, mean LV perfusion was significantly reduced in patients with normal coronary arteries who had cariomyopathy and impaired ventricular performance. Mean LV perfusion was not significantly different from control values in patients with "mild" coronary artery disease (less than 50% obstruction) or in patients with significant isolated disease (greater than 50% obstruction) of the left anterior descending (lad) artery. Significant reductions in mean LV perfusion were found in patients with greater than 50% obstruction of two coronary arteries (LAD + right or LAD + circumflex) and in patients with triple-vessel disease. The average perfusion rate for regions distal to LAD obstructions in patients with isolated LAD disease was not lower than the LAD perfusion in control patients, but was significantly reduced in patients with LAD + right coronary artery disease (43+/-14 ml/100 g-min). In the latter group average perfusion distal to the LAD lesion was significantly lower than the average regional perfusion rate for the remainder of the LV. However, the mean blood flow rate for the remainder of the LV was also significantly lower than control values despite the lack of significant circumflex disease. The data demonstrate that the presence of radiographically "mild" or significant isolated LAD coronary disease is not associated with reductions in mean LV perfusion at rest, but that mean LV perfusion is reduced in the presence of significant disease of two or three coronary artieries. None of the patients experienced angina during the resting studies and most had clinical evidence of ventricular failure. The observation of depressed LV perfusion in this group, as in the patients with cardiomyopathy, raises the possibility that a lowered resting blood supply may be adequate for a reduced level of performance of a diseased ventricle. The lack of selective reductions of regional perfusion at rest in the majority of the patients with LAD lesions suggests that regional myocardial blood flow must be measured during an intervention which increases myocardial oxygen consumption in order to assess the physiological significance of lesions which are observed at coronary arteriography.

Myocardial blood flow (MBF) per unit mass was measured in 10 patients (pts) with severe aortic stenosis (AS) and no significant aortic insufficiency, normal ejection fractions, and normal coronary arteriograms, using xenon-133 and a multiple crystal scintillation camera. MBF per unit mass was reduced in AS (53 +/- 13 mg/100g.min) in comparison to a group of seven normal control patients (69 +/- 12 ml/100g.min) (P less than 0.05). When normalized for heart rate. MBF remained depressed in aortic stenosis (0.65 +/- 0.11 ml/100 g.beat). MBF/beat was strongly related to peak left ventricular wall stress in both groups (r = 0.97). Individual values of MBF/beat were normalized for peak stress using an analysis of covarience; the adjusted mean values were 0.62 +/- 0.03 ml/100g.beat for the AS patients and 0.84 +/- 0.03 ml/100 g.beat for the control patients. There was no overlap between groups in adjusted MBF per beat. Values of MBF per beat and peak stress for a group of ten cardiomyopathy patients with depressed contractility were observed to fall close to the regression line for AS patients. The results suggest that variability in resting MBF in these AS patients is due primarily to differences in LV stress and that reduction in MBF per beat in this group may be due to reduced contractility.

Myocardial blood flow/unit mass (MBF) and the determinants of myocardial oxygen consumption were measured in seven control subjects (group I) and 15 patients (pts) with cardiomyopathy (CM), group II (group IIa-congestive CM: 10 pts; group IIb-hypertrophic CM: 5 pts). In group I left ventricular (LV) MBF was 64 +/- 8 (SD) ml/100g-min; it was significantly lower in IIa (45 +/- 15 ml/100g-min, P less than 0.01) and IIb (39 +/- 7 ml/100g-min, P less than 0.01). However, calculated total LV flow (LV mass X MBF) was increased in the two CM groups. In nine CM pts, LV MBF increased in response to atrial pacing from 41 +/- 7 to 63 +/- 13 ml/100g-min. In group IIa, calculated peak wall stress was normal (4.39 +/hortening (MVcf) was significantly reduced (0.53 +/- 0;18 vs 1.26 +/- 0.12 circum/sec, P less than 0.01). In IIb, MVcf was normal but peak stress was significantly reduced (2.80 +/- 0.75 vs 4.51 +/- 1.10 dynes/cm2 X 10(5), P less than 0.05). Multiple regression analysis based on all pts yielded, MBF - 16.9 MVcf + 9.30 Stress + 0.26 Heart Rate - 26.4 (r=0.79). The data indicate that MBF is reduced in CM patients and the regression analysis suggests that MBF in these 22 pts with normal coronary arteriograms was determined largely by heart rate, peak stress, and ventricular performance.

Pulmonary atresia with intact ventricular septum is an uncommon congenital anomaly associated with a 15% mortality within the first month of life. The anatomic diagnosis requires complete atresia of the pulmonary valve, usually with survival based on the presence of a foramen ovale and a patent ductus arteriosus supplying the pulmonary blood flow. The main pulmonary arteries usually are of normal size, and there is often an abnormality of the tricuspid valve—being either small in size or associated with severe tricuspid regurgitation. There is a spectrum of right ventricular sizes associated with the anomaly, from a miniscule right ventricle to one that appears normal with a well-developed outflow tract.

Between 1974 and 1979 nine patients, aged 10 months to 4 years, underwent left ventriculotomy for closure of single or multiple defects in the muscular ventricular septum. The vertical incision paralleled the anterior descending branch of the left coronary artery near the apex of the left ventricle and ranged from 2.5 to 3.5 cm in length. Four patients also had a right ventriculotomy with closure of a high perimembranous ventricular defect in two. Serial electrocardiograms indicated changes of myocardial ischemia or necrosis. Left bundle branch block did not develop in any patient. Three patients died in the early postoperative period. The six surviving patients are living and well 2 to 7 years later. There is apparent complete closure of the ventricular defects, which was documented by cardiac catheterization in four cases. Two patients had cardiomegaly and left ventricular dysfunction as assessed with echocardiographic and angiographic study, whereas four displayed good cardiac function. In three of the latter patients, cardioplegia or deep hypothermia techniques were utilized intraoperatively. The observations indicate that left ventriculotomy of limited size is an acceptable approach to the difficult problem of repair of muscular ventricular defects but may involve some risk of compromise of the coronary circulation.

Comparison of left ventricular volume determinations by cross-sectional ultrasonography, single-axis echocardiography, and biplane angiography suggests that the cross-sectional technique may be able to determine left ventricular volumes within a clinically useful range of accuracy. Sources of error and means of avoiding them are discussed.

Three patients with total anomalous pulmonary venous drainage and ventricular septal defect with left-to-right shunt are presented. The ventricular septal defect was diagnosed with left ventricular angiocardiography in two patients and confirmed on postmortem examination in the third. The complex hemodynamic implications of this combination of lesions are discussed. Pulmonary artery banding is suggested as a possible method of management in early infancy. When total anomalous pulmonary venous drainage is demonstrated in infants initially suspected of having large ventricular septal defects on the basis of auscultation, left ventricular angiocardiography is mandatory. Preoperative diagnosis of a complicating ventricular septal defect is essential to optimal management.

THOUGH over 500 cases of hereditary angioneurotic edema have been reported (1, 5, and 6) the subject is virtually unknown in the radiologic literature. Weare presenting the findings of marked regional edema involving the mid small intestine of a young woman with hereditary angioneurotic edema during an episode of severe abdominal pain. Since such episodes of abdominal pain are characteristic of this disorder, radiologists should be aware of the roentgenographic manifestations. Angioneurotic edema, as described by Quincke in 1882 and by others (1), is characterized by recurrent episodes or attacks of acute circumscribed noninflammatory edema (periodic edema (11)) which are of sudden onset and regional in distribution. The involved region is swollen, tense, and pale, but not red or warm. Only occasionally is there itching, and other signs of acute inflammation are typically not found. Pitting on pressure does not occur until the lesion begins to regress. This is spontaneous, usually after twelve to forty-ei...