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SUMMARYThis is a case report of sudden death in a 50 year old man with a history of recent onset of atypical anginal pain. Death appears to have been caused by a small papilloma attached by a pedicle to the edge of the right cusp of the aortic valve. This papilloma occluded the right coronary ostium in a heart with a predominant right coronary circulation.Additional Indexing Words: AnginaRight coronary ostium T HIS PATIENT died 23 years ago. The case was not reported at the time because it was thought to be too rare, that it would be impossible to diagnose by methods then available, and that it would require color illustrations which were then not used by most medical journals.At this time many of these problems have changed and the case is now presented briefly because with modern methods of cineangiography and perhaps echocardiography such a diagnosis might be made in vivo and corrected surgically. HistoryThe patient was a 50 year old male with no significant family history or past history of cardiovascular disease. Eight days prior to admission to the University Hospital the patient developed sudden onset of severe constricting precordial pain with radiation into both arms. This persisted intermittently and was aggravated by exercise but also occurred at rest. After three days he consulted a physician who did not take an electrocardiogram but prescribed nitroglycerine which gave some, but not always complete, relief. He was seen by one of us (CAP) five days later. The electrocardiogram showed an isoelectric T in aVL and negative T waves in the chest leads 4 and 5 (these may have been CF leads). Laboratory Findings. RBC 4.5 million/mm', Hgb 14.5 g/ 100 ml, WBC 9,500/mm3 with a normal differential. The sedimentation rate was 1 mm/hour and the serum cholesterol was 175 mg/ 100 ml.Course. The patient was placed on dicumerol therapy. We were puzzled by the atypical nature of the anginal attacks which came on without any particular relation to activity, ingestion of food or emotional upsets during hospitalization and often occurred when the patient was sitting or lying quietly. An electrocardiogram was taken five days after admission and although the T in aVL was still slightly negative the T waves across the precordium (V leads) were all positive. On the eighth hospital day the patient was found dead in bed at 4:15 p.m.; death had evidently occurred only a short time before. AutopsyThe pertinent findings as recorded by the pathologist were as follows:Heart: Weighs 400 grams and measures 13.0 x 9.0 x 6.5 cm. The relation of the great vessels is natural. The epicardium is everywhere smooth and glistening. The organ feels firm. The left auricle is not remarkable. The mitral valve has a circumference of 9.5 cm. Its leaflets are pliable and competent. The chordae tendineae are long, thin and straight. The papillary muscles are normal. The

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