ECG of the month. Cardiac failure and stroke in a 43-year-old woman. Coarse atrial fibrillation indicating left atrial enlargement and left ventricular hypertrophy with repolarization abnormality.

A 43-year-old woman with a long history of heavy cigarette smoking was in good health until she developed fatigue, dyspnea on exertion, and paroxysmal nocturnal dyspnea approximately three months before admission to our hospital. Four weeks before admission, she was admitted to another hospital for the sudden onset of a right hemiparesis. She was noted to be in atrial fibrillation, and cardiac catheterization and angiocardiography revealed triple-vessel coronary arterial disease and moderately severe mitral regurgitation. Because of repeated episodes of paroxysmal nocturnal dyspnea, she was referred to our hospital for cardiac surgery. On admission, an electrocardiogram was recorded (Figure).

Ecg of the month. Unusual electrocardiogram 42 years after operation for supravalvular aortic stenosis and 6 years after aortic valve replacement. Sinus rhythm with first degree atrioventricular block.

A 43-year-old man came to the hospital because of increasing dyspnea for two weeks. At age nine months the patient was evaluated for failure to thrive, and a diagnosis of valvular aortic stenosis was made. At operation the aortic stenosis was found to be supravalvular, and the ascending aorta was enlarged with a Teflon patch, the proximal end of which was placed in the noncoronary sinus of Valsalva. The aortic valve was bicuspid but otherwise appeared normal. Postoperatively the patient did well until six years ago when he developed increasing dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Echocardiography revealed a peak systolic pressure gradient across the aortic valve of 80 mmHg, severe aortic regurgitation, and moderate mitral regurgitation thought to be functional. Coronary arteriograms were normal. The patient underwent aortic valve replacement with a 23 mm Hancock 2 porcine heterograft prosthesis. He again did well postoperatively until a year before the current admission when dyspnea on exertion developed and culminated in two weeks of severe orthopnea and paroxysmal nocturnal dyspnea. The electrocardiogram (ECG) recorded on admission is shown in the Figure.

Repair of large, iatrogenic, tracheo-esophageal fistulae.

Closure of large, iatrogenic, tracheo-esophageal fistulae present a formidable technical challenge. Our method of repair is presented, which describes the exposure and subsequent closure that relies on creating a new "membranous" trachea using remnant flaps of the esophageal wall of the fistula.