The risk of late sudden death for patients surviving operation for common congenital heart defects is 25 to 100 times greater than an age-matched control population. This increased risk is primarily represented by patients with cyanotic or left heart obstructive lesions. The risk of sudden death appears to be time dependent, increasing primarily after the second postoperative decade.

Background-Patients who undergo ring annuloplasty for ischemic mitral regurgitation (MR) often have persistent or recurrent MR. This may relate to persistent leaflet tethering from left ventricle (LV) dilatation that is not relieved by ring annuloplasty. Therefore, the purpose of this study was to test the hypothesis that recurrent MR in patients after ring annuloplasty relates to continued LV remodeling. Methods and Results-Serial echoes were reviewed in 30 patients (aged 72Ϯ11 years) who showed recurrent MR late (47Ϯ27 months) versus early (3.8Ϯ5.8 months) after ring annuloplasty for ischemic MR during coronary artery bypass grafting without interval infarction. Patients with intrinsic mitral valve disease were excluded. Echocardiographic measures of MR (vena contracta and jet area/left atrial area) and LV remodeling (LV dimensions, volumes, and sphericity) were assessed at each stage. The degree of MR increased from mild to moderate, on average, from early to late postoperative stages, without significant change in LV ejection fraction. Changes in MR paralleled increases in LV volumes and sphericity index at end-systole and end-diastole. The only independent predictor of late postoperative MR was LV sphericity index at end-systole. Conclusions-Recurrent MR late after ring annuloplasty is associated with continued LV remodeling, emphasizing its dynamic relation to the LV.

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Wolf-Parkinson-White syndrome underwent electrophysiological studies for drug refractory supraventricular tachycardia. Intracardiac mapping of the accessory pathway performed during orthodromic supraventricular tachycardia and preexcited sinus rhythm revealed earliest retrograde atrial activation and earliest ventricular activation, respectively, in the inferior and paraseptal region of the right atrioventricular groove. Radiofrequency applications to this region, however, failed to terminate supraventricular tachycardia, or to eliminate the preexcitation. A transseptal puncture was performed, and the inferior paraseptal region was mapped, but electrograms with early activation were not observed. Accordingly, angiography was then performed with an end-hole catheter advanced into the coronary sinus via the internal jugular vein. This demonstrated a diverticulum of the coronary sinus (arrows) with a discrete narrow neck 1 in the right (Fig. 1a) and the left (Fig. 1b) anterior oblique projections. A hexapolar diagnostic electrophysiology catheter is seen at the Images in Congenital Heart DiseaseDiverticulum of the coronary sinus complicating ablation of an inferior paraseptal pathway in an 18-month-old child

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