A case of complete cleft sternum is presented along with the nomenclatuie of sternal defects. It is recommended that the term ectopia cordis should be applied only to cases in which the heart and thoracic viscera are genuinely ectopic. A 10-day-old infant from Saudi Arabia was admitted to the Brompton Hospital in January 1974. She was the product of a full-term, uncomplicated pregnancy and normal delivery. The parents and three siblings were well and without congenital abnormality.On examination the infant was well nourished and weighed 3-4 kg. There was an ellipse of abnormal, partly ulcerated pink skin on the anterior chest with no apparent sternum deep to it (fig la). This left a defect between the ribs, which was up to 5 cm across. The heart and thoracic viscera could be seen and felt to move paradoxically in this defect during respiration, and protrude through it alarmingly when the child cried (fig lb). It was possible to approximate the ribs in the midline by applying gentle lateral pressure. This manoeuvre did not embarrass resriration or affect blood pressure. The heart sounds, which were normal, and the cardiac impulse were most easily detected to the right At operation a vertical elliptical incision was made excising the abnormal skin. The pericardium, which was adherent to the skin, was opened inadvertently and immediately closed by suture. A complete cleft sternum was found; the sternal bands were well formed and converged inferiorly to the linea alba of the abdominal musculature. There was no deficiency of the abdominal musculature or diaphragm, but the pectoral and sternomastoid muscles were separated by the span of the sternal defect. The sternal bands were dissected free of the pleura and their medial borders freshened. They were then approximated with interrupted nylon sutures without difficulty. Cardiorespiratory embarrassment did not occur, and the closure was completed with subcutaneous and skin layers. No muscular layer was required as the pectoral and sternomastoid muscles assumed a normal position with closure of the sternum.The child made an uneventful recovery and was discharged from hospital on the eleventh day after operation.We have recently reviewed this child who is now a healthy 5-year-old. She has developed normally and is asymptomatic. Physical examination is unremarkable apart from an inconspicuous midline scar and an apex beat which is still displaced to the right. The thoracic cage is welldeveloped, symmetrical, and without deformity. 303 on 11 May 2018 by guest. Protected by copyright.

A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

We describe here a case of intrathoracic goitre located in the posterior mediastinum causing superior vena caval obstruction. Case reportA 45-year-old woman was admitted to the Cardiothoracic Unit complaining of increasing dyspnoea for six months. She had a dry cough, no haemoptysis and no dysphagia but she had noticed some change in her voice in the previous three months.She had no chest pain, but said that she had swelling of the face and lower limbs, mainly in the evenings. She had lost 7 kg in the previous two months.Her past history included three unknown abdominal operations, and an ovarian cyst had been removed 10 years previously. The histological diagnosis was unknown. Thyroidectomy was also performed in that period. On examination, her general condition was good, but signs of superior vena caval obstruction were obvious. The trachea was deviated to the right and a fixed nodule, 3 cm in diameter, was present in the area of the old thyroidectomy scar. The lungs were clear and the heart sounds were normal. Blood pressure was 130/80 mmHg, pulse rate 80 beats per minute and regular. The abdomen and central nervous system were normal.The haematocrit, haemoglobin, white cell count, urea and electrolytes were within normal limits. The chest radiograph ( figure) showed a large mediastinal mass, deviating the trachea to the right. Tomograms of this area revealed this mass to be solid, and situated in the posterior mediastinum. Radioiodine scanning of the neck showed a solitary nodule, and the mediastinal mass was also taking up iodine.With a provisional diagnosis of intrathoracic goitre, and to exclude the possibility of a malignant tumour, a mediastinotomy was performed resecting the second left costal cartilage, when the mass was biopsied. Frozen section confirmed the presence of thyroid tissue with no evidence of malignancy. After this, a "collar" incision was made, and the nodule present in the cervical area was removed.A median sternotomy was performed with the intention of removing the intrathoracic mass. A large tumour weighing 300 g was removed from the

Three cases of gunshot wounds of the chest are reported, in each of which a bullet was retained within the heart. Although it is rare, the surgeon should consider this possibility if the missile overlies the cardiac silhouette on the plain chest radiograph. Fluoroscopy played an important part in confirming the diagnosis. Cardiopulmonary bypass was used in all cases and provides operating circumstances that improve the prospects of success.Despite the increasing number of casualties resulting from penetrating chest injuries, retained foreign bodies inside a cardiac chamber are very rare in civilian life. Among the few reports referring to intracardiac bullets or shell fragments,' -9 the most interesting and important experience was published by Harken,1 2 based on his second world war experience. More recently, with the increasing sophistication of civilian weapons and in particular their increased calibre and muzzle velocity, a cardiac injury produced by such devices often causes extensive damage and the bullet usually passes right through the heart. Nevertheless, there is always the possibility, depending on the circumstances, that a bullet or a fragment has remained inside the heart. Three cases are described here, in each of which a bullet fired from a low velocity gun lay completely free inside a ventricular cavity after penetrating the muscular cardiac wall. She was immediately taken to the operating theatre and the chest was opened by a median sternotomy. After the pericardium had been opened and clot removed cardiac function improved immediately. Since a bullet was known to be within the heart, cardiopulmonary bypass was instituted and the ascending aorta and the superior and inferior venae cavae were cannulated. The aorta was clamped and a cold cardioplegia solution was infused through the ascending aorta. A small perforation was identified on the right ventricular outflow tract. The right ventricle was opened through a small transverse incision and inspection showed that the bullet had also perforated the interventricular septum. The left atrium was opened and a tear in its posterior wall was exposed. The bullet was identified in and removed from the left ventricular cavity, which was inspected through the mitral valve. After the right ventricle, the left atrium, and the interventricular septum had been repaired cardiopulmonary bypass was withdrawn. The patient had an uneventful recovery and was discharged from hospital on the 10th postoperative day. Twenty months later she is leading a normal life.

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This is a case report of a 48-year-old female patient with a compatible history of Kawasaki disease during childhood, who was admitted to the emergency coronary unit with unstable angina pectoris. Coronary angiography identified two coronary aneurysms, one causing right coronary occlusion and the other causing severe obstruction of the left anterior descending coronary artery. Coronary artery bypass surgery was indicated.

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