Two cases are described in which the systemic and pulmonary blood streams cross at atrioventricular level. One was examined pathologically, the other was diagnosed at cardiac catheterization by angiography. Both possessed situs solitus, but in one heart the right atrium was connected to a morphologic right ventricle on the left, whereas in the other it was connected to a left-sided morphologic left ventricle. In both cases transposition of the great arteries was present. The cases have been interpreted as representing rotation of embryonic dand 1-bulboventricular loops following septation.In attempting to describe these heart difficulties in terminology were encountered which were partially overcome by combining the concepts of concordant and discordant atrioventricular relationships with those of transposition and malposition. However, to give an accurate interpretation of the hearts, it proved necessary to include a term indicating rotation of the bulboventricular loop following septation. Thus the hearts were described as situs solitus, discordant (d-rotated) loop with d-transposition, and situs solitus, concordant (1-rotated) loop with 1-transposition.

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Although the malformation in itself seems to be of no functional importance, we assessed its importance in terms of associated conditions and its possible relevance to subsequent operations. Case reports CASE 1This girl died when she was 5 years 11 months old after cerebral ischaemia after attempted surgical correction of tetralogy of Fallot. Postmortem examination of the heart showed usual (solitus) atrialRequests for reprints to Dr Leon M Gerlis,

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suMMARY Discrete delicate fibromuscular structures crossing the cavity of the left ventricle were identified on morphological examination in 329 (48%) of 686 hearts from patients of all ages with congenital heart disease, acquired heart disease, or normal hearts. These structures were also present in 151 (95%) of 159 hearts from animals of six species. Cross sectional echocardiographic findings compatible with these structures were obtined in 39 (21-7%) of 179 children reviewed retrospectively and in three of 800 (0-4%) adults studied prospectively. These structures appear to be a normal anatomical finding.Isolated examples of filaments of tissue crossing the cavity of the left ventricle were first reported in 1893 by Turner. '-3 In 1906 Keith and Flack noted that they were almost constantly present in both bovine and human hearts and they regarded them as being part of the left bundle branch distribution of the Purkinje conduction fibres.4 Although these structures are hardly mentioned in the standard textbooks of anatomy and cardiac pathology,56 the development of echocardiography appears to have reawakened interest in them.7-1 ' We made a quantitative morphological assessment of the prevalence of these structures as this would seem to be a prerequisite for an appraisal of their importance. For reasons that we will discuss later we have called these structures left ventricular bands. Patients and methodsWe reviewed 686 hearts in the collection of this hospital specifically for the presence of left ventricular bands. Six hundred and thirty six were from children below the age of 15. Of these, 581 had had congenital cardiac malformations and 55 had had normal hearts. The 50 other hearts were from adults who had previously had surgery for acquired cardiac disease. We also examined 159 hearts from six species of animals Accepted for publication 31 July 1984 (none of which was killed for the purpose of the study). Ventricular bands were identified as discrete fibromuscular structures crossing the left ventricular cavity and having no attachment to the atrioventricular valve (Fig. 1). They extended from a papillary muscle to the septum, from a papillary muscle to the free wall, between the papillary muscles, or from the septum to the free wall. They were either single or multiple and sometimes branched. Small multiple strands at the junction of the setpum with the free walls were disregarded as were small apical networks.In addition to the morphological study, we reviewed cross sectional echocardiograms from 800 adults and 179 children. Adult echocardiograms had been recorded on a Varian V3400 phased array system with a 2*2 MHz transducer.

An immunologic basis for congenital heart block has been proposed previously. To investigate the association between congenital heart block and maternal antibodies capable of crossing the placenta, we used immunofluorescence to examine serum samples from 41 mothers and 8 affected children, together with serum from controls, for antibodies to fetal cardiac tissue. Twenty-one mothers (51 percent) had IgG antibody reactive with fetal heart tissue, as compared with only 9 of 94 controls (10 percent; P less than 0.001). Three of 8 affected babies, but none of 50 healthy babies, had similar antibodies. The antibodies reacted with all myocardial tissue and were not directed specifically to the conduction system. They also reacted with other fetal tissues and could be distinguished from nuclear and smooth-muscle autoantibodies. We also observed a higher occurrence of antibodies to cytomegalovirus, but not to Epstein-Barr virus, in these mothers. Autopsy specimens from babies with congenital heart block examined by immunoperoxidase staining showed deposition of immunoglobulin and complement components in all cardiac tissues. These findings strengthen the case implicating immune reactivity related to maternal antibody in the development of some but not all cases of congenital heart block.

SUMMARY A short review of two chambered left ventricle is given, and this rare condition is briefly compared and contrasted with the more common condition involving the right ventricle. Three cases are described, each of which presents a new variety of subdivision of the left ventricle; in two of these the condition was first shown by angiocardiography. The first case had left heart hypoplasia with dysplastic stenosis of the mitral and aortic valves and severe endocardial fibroelastosis of the main left ventricular cavity. The second case also showed dysplasia of the left sided valves with pronounced endocardial fibroelastosis, and in addition there was a congenital malformation of the left lung. The third case showed a bizarre ventricular subdivision without other congenital malformations.The role of the intertrabecular myocardial sinusoids in the pathogenesis of some types of two chambered ventricle is discussed and this is considered to have been of significance in the first two cases. The third case possibly represented an intramyocardial aneurysm of obscure aetiology.

The conditions variously described as Uhl's anomaly and arrhythmogenic dysplasia are separate and distinct morphological entities.