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Early growth velocity was generally <20 g/day whereas normal infant growth is 25 g/day buy trileptal master card. These initial data prompted a greater focus on ensuring adequate caloric intake prior to hospital discharge and increased attention to outpatient growth and nutrition order generic trileptal on-line. In an attempt to optimize adequate growth 150mg trileptal overnight delivery, infants are expected to take 110 to 130 kcal/kg/day with formula or breast milk fortified to 24 to 27 calories per ounce. Approximately 25% of our patients have undergone open gastrostomy tube placement P. Increased attentiveness to nutritional intake at our institution has resulted in improved somatic growth in monitored patients that nearly parallels normal infant growth with a growth velocity >25 g/day (Fig 46. All groups demonstrated improved weight-for-age Z-score during the interstage period. In this cohort of 465 patients, 56% required supplementation with a feeding tube at stage 1 hospital discharge with a reduction of 37% needing supplementation by stage 2 palliation. Top panel: Growth pattern of study cohort parallels Center for Disease Control normal infant growth. Bottom panel: Improved growth velocity in recent era associated with interstage program modifications in nutritional care. Normal interstage growth after the norwood operation associated with interstage home monitoring. Anesthetic management usually includes a more balanced anesthetic technique that avoids prolonged postoperative ventilation, and approaches that include neuraxial opioids may have a favorable effect on early postoperative management (361). Progression to the cavopulmonary anastomosis reduces both wall stress and atrioventricular valve insufficiency through elimination of the volume load on the single systemic ventricle. It creates a more efficient in-series circulation and increases diastolic pressure with improved coronary artery perfusion (241,253,345). The delayed timing of stage 2 palliation to 6 months of age has been supported by previous reports that early cavopulmonary anastomosis has been associated with severe hypoxemia, prolonged pleural drainage, pulmonary artery thrombosis, poor pulmonary artery growth, early development of pulmonary arteriovenous malformations, and excess mortality (362,363,364,365). However, it seems logical that by simply shortening the period of risk linked to the inefficient parallel circulation after stage 1 palliation, interstage survival will be enhanced. In a series of home-monitored patients, those who breached home-monitoring criteria proceeded to stage 2 palliation at a significantly younger age of 3. Despite the younger age at stage 2 palliation of the monitored patients, weights between groups were similar: 5. The success of early cavopulmonary anastomosis in these patients deemed at greatest risk for interstage mortality has modified our overall practice in that stage 2 palliation is electively performed at 4 months of age or earlier if necessary. The implications of early cavopulmonary anastomosis have been further reviewed by Jaquiss et al. The younger group, however, required prolonged mechanical ventilation, had a greater duration of pleural drainage, and had a longer hospital stay. Younger patients also had lower oxygen saturations postoperatively compared with the older group, but by hospital discharge, groups had similar oxygen saturations (365). A: In a hemi-Fontan procedure, the superior vena cava is connected to the confluent pulmonary arteries without disconnecting it from the atrium; the atrial end of the superior vena cava is closed with a patch. Although a more extensive operation than the bidirectional Glenn shunt, the hemi-Fontan allows for expeditious performance of a completion Fontan. B: The bidirectional Glenn shunt is a direct anastomosis of the superior vena cava to the central pulmonary artery. The principle advantage of the bidirectional Glenn shunt is the ease of construction; it can even be accomplished without the use of cardiopulmonary bypass in selected cases. Outcomes at the stage 2 operation including mortality and prolonged hospital length of stay have not been shown to be influenced by shunt type. After the stage 2 operation, patients experienced improved activity and physiologic reserve, which lasted several years. However, increasing cyanosis following stage 2 palliation is predictable and is due to several factors including increased lower-body growth and oxygen consumption with concomitant increase in desaturated inferior vena caval blood return. Furthermore, patients are at risk for the development of arteriovenous malformations that result in intrapulmonary shunting of blood from pulmonary artery to pulmonary vein without gas exchange. These are postulated to be the result of a lack of the so-called hepatic factor, which prevents the shunt formation (368). Pulmonary arteriovenous malformations can be reversed by the completion Fontan operation, presumably by restoring hepatic factor to the pulmonary circulation. A: The lateral tunnel Fontan involves creating an intra-atrial baffle that connects the inferior vena cava to the pulmonary arteries. B: The extracardiac Fontan uses a tube graft to connect the inferior vena cava to the central pulmonary artery. In both cases all caval return with the exception of the coronary sinus is directed to the pulmonary arteries, simulating as closely as possible the normal circulatory pattern. To improve hemodynamics, especially in the early postoperative period, a fenestration is often placed between the baffle or conduit and the pulmonary venous atrium. This decreases central venous pressure and increases preload to the single ventricle, albeit at the cost of some systemic desaturation. For patients who have undergone a stage 2 procedure, either a bidirectional Glenn shunt or hemi-Fontan, the timing of completion Fontan is not critical; in general, the operation is performed between 18 months and 4 years of age, with anesthetic considerations similar to those for the stage 2 operation. Although interventional techniques to perform the completion Fontan using coated stents have been reported, much more commonly this is performed in the operating room using one of two techniques; a lateral tunnel or extracardiac conduit (Fig. As part of the hemi-Fontan, a dam is constructed between the pulmonary arteries and the right atrium. During the completion Fontan, this dam is removed and a section of prosthetic conduit is used to create a baffle to route the inferior caval blood return to the pulmonary artery. Additional advantages include a low level of power loss as determined by computational fluid dynamic studies (369). Although controversial, some studies suggest a higher incidence of sinus node dysfunction following the lateral tunnel Fontan (370,371,372,373,374). Another potential disadvantage of the lateral tunnel Fontan involves the presence of prosthetic material exposed to the pulmonary venous portion of the atrium with the potential for thrombus formation and systemic embolization. The advantages include the ease of the operation and, although somewhat controversial, probably a lower incidence of sinus node dysfunction (370,371,372,373,374). In addition, no prosthetic material is placed in the pulmonary venous atrium, with potentially lower risk of thromboembolic complications. To this end, larger conduits, between 20 and 22 mm in diameter, are placed to accommodate growth. The larger and longer conduits may result in power loss, which, when combined with the potential for late revision for outgrowth, may impact the durability of the extracardiac Fontan. The use of a fenestration has resulted in excellent survival and shorter hospital stay (238). Additional strategies that minimize postoperative hospital stay include routine use of the diuretics including spironolactone, an aldosterone antagonist, and furosemide. Supplemental oxygen is used as a pulmonary vasodilator, and afterload reduction is given to improve cardiac output and lower single-ventricle filling pressures (375). Outcomes for Staged Palliation Most mortality associated with the staged surgical approach occurs during and after stage 1 palliation, with recent cumulative early and interstage mortality in the 5% to 30% range (88,273,376,377). Improved outcome has been associated with early diagnosis, preoperative stabilization, early repair, systematic management approaches, and increased monitoring both in-hospital and at home (86,88,345).

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The posterior vertical cut needs to enter the maxillary sinus adjacent to the posterior wall of the maxillary sinus and into the large antrostomy5 (Fig buy discount trileptal 150mg. Once the bone forming the medial maxillary wall is mobilized buy cheap trileptal 300mg online, the nasolacrimal duct will tether the bone an- teriorly and the duct will be visualized (Fig safe trileptal 150 mg. Note the microdebrider blade that has been placed through the canine fossa trephine. Tumor can now be sinus, further resection of the anteromedial wall and frontal removed from the maxillary sinus under direct visualization. In such If additional access is required and the tumor does not attach cases a canine fossa trephine is not thought to be suitable due to the anterior wall of the maxillary sinus, a canine fossa to the small risk of seeding the tumor into the soft tissues of puncture can be performed. Although seeding is unlikely to occur, this risk is endoscope to be introduced through the anterior wall of the thought to be greater if the entry point into the maxillary sinus maxillary sinus which can be useful to access areas within the is through tumor rather than through normal mucosa. This access is achieved the required angle for dissection in difcult areas such as the by performing a hemitransfxion incision in the opposite nasal anterior wall or anterolateral region of the maxillary sinus. The instrument can then that attaches extensively to the anterior face of the maxillary be passed through the hemitransfxion incision, through the Fig. This allows the passage of a 70-degree dia- fxion incision anteriorly in the left nostril (contralateral side to the mond tipped drill (D). C, carti- right nasal cavity demonstrating the working tip of the drill passing into lage; F, fap. The mucosa giving greater access to the anterior wall of the maxillary sinus from the posterior wall of the maxillary sinus is elevated (Fig. This exposes the bone and removal of this of approach and usually allows complete access to the entire bone is necessary to expose the pterygopalatine fossa. The punch Access to the Pterygopalatine Fossa (Videos 41 and 42) is introduced into the sphenopalatine foramen and the bone anterior to the foramen removed until the posterior Access to the pterygopalatine fossa is achieved by remov- wall of the maxillary sinus is reached (Fig. In most cases removal of this bone can be done either with the punch a medial maxillectomy is unnecessary as most of the ptery- or with a 45-degree through-biting Blakesley. Bone is re- gopalatine fossa can be accessed through a large middle moved until the contents of the pterygopalatine fossa are meatal antrostomy. In addition the vidian nerve enters the posterior aspect of the fossa before moving laterally to end in the pterygopalatine ganglion which is suspended from the maxillary nerve (Fig. The pterygopala- tine fossa narrows gradually as it opens laterally into the region of the infraorbital fssure and pterygomaxil- lary fssure before widening into the infratemporal fossa (Figs. The roof of the pterygopalatine fossa is formed by the greater wing of the sphenoid bone and the infraorbital fssure, foramen rotundum, and the maxillary nerve coursing from the foramen rotundum from medial to lateral across the roof of the fossa just below the orbital apex (Figs. The frst fact to be appreciated is that the pterygopalatine fossa forms a relatively small part of the total area behind the posterior wall of the maxillary sinus Access to the Infratemporal Fossa (Videos 41 and 42) (Fig. Second the frst structures to be encountered when entering the fossa are the blood vessels (Fig. To access the infratemporal fossa, all of the bone of the pos- The neural structures all lie deep to this plexus of arteries terior and lateral wall of the maxillary sinus needs to be (Fig. Most of the bone can be removed through the same Further dissection in the roof to the fossa allows the maxil- nostril as the tumor using either the Hajek-Kofer punch or lary nerve to be seen just below the orbit in the roof of the through-biting Blakesley. If this nerve is followed posteromedially the foramen should be removed from the roof to the foor of the maxillary rotundum can be seen (Fig. The septal port for the infratemporal fossa is very similar to that The Endoscopic Anatomy of the Infraorbital Fissure used to access the front wall of the maxillary sinus. This angle of approach allows the instruments to be advanced up to the The other relationship that is important to understand is anterior maxillary sinus wall as described under “Maxillary how the pterygopalatine fossa and infratemporal fossa relate Sinus Access. It is through this fssure that tumors can extend from the infratemporal fossa and pterygopalatine fossa up toward the orbital apex. Additionally, tumors may follow the infraorbital nerve and maxillary nerve to enter Endoscopic Anatomy the pterygopalatine fossa and move posteriorly toward the cavernous sinus and carotid artery. Endoscopic Anatomy of the Greater Palatine Canal As the orbital apex and sphenoid is approached, the inferior and the Pterygopalatine Fossa portion of the lamina papyracea thickens. The lateral wall of the fssure is formed by the medial wall of the middle cranial The greater palatine canal and the pterygopalatine fossa fossa. The pterygopala- infraorbital fssure and it is around this structure that tumor tine fossa is similar to an inverted cone and the bottom can insinuate to reach the orbital apex and then expand into 208 Endoscopic Sinus Surgery D Fig. The vidian canal can be seen entering the white line and the sphenopalatine foramina are indicated with the white ar- posterior wall of the pterygopalatine fossa (black arrow). The posterior wall of the maxillary sinus has the infraorbital fissure are continuous with each other. Signifcant expansion can occur so that the tumor may reach the cavernous sinus and even the carotid artery. To understand how the medial aspect of the infra- orbital fssure can be surgically accessed, Figs. Note how the medial part of the fssure communicates with the pterygopalatine fossa whereas the lateral part of the fssure communicates with the orbit. Note the landmarks of the lateral wall including the optic nerve, the anterior genu of the intracavernous carotid artery, the maxillary impression for the maxillary division of the trigeminal nerve, and the vidian nerve in the foor of the sphenoid sinus. The blue silicone shows the anterior genu of the intracavernous carotid is completely within the cavernous sinus. The anterior limit of this marks the beginning of the orbital apex, the supraorbital fssure. The occulomotor, trochlea, and ophthalmic division of the tri- geminal nerve can be seen in Fig. In this image the periorbita of the orbital apex has been retracted with a Freer dissector. Analysis of the maxillary nerve can clearly show the path which tumors in this region may take. Head- ing posteriorly they may enter the cavernous sinus and in- vade the intracavernous structures such as the intracavern- ous carotid artery. This depression corresponds to pneumatization of To access the region of the middle cranial fossa and fora- the optic strut (the bony bridge that separates the optic canal from men ovale, further removal of the lateral wall of the sphe- the superior orbital fssure). To achieve this both the vidian may result in a pneumatized anterior clinoid process which will place nerve in the foor of the sphenoid sinus and the maxillary the optic nerve on a mesentery. The bone has been removed and the anterior genu of following removal of the lateral sphenoid wall. This allows anteriorly to the pterygopalatine fossa inferiorly and the orbital apex su- clear visualization of the nerves within the dural layers of the lateral periorly. Note the periorbita the foramen rotundum from the superior orbital fssure/orbital apex. This relationship is important as it helps one to un- the right maxillary nerve and the infraorbital fssure and the pterygopala- derstand how tumors spread from one fossa to another and on occasions tine fossa as viewed from an anterosuperior aspect. Although dura covers the cavernous sinus as it is approached from the sphenoid sinus, this covering is very thin and tenuous with multiple small veins joining or leaving the cavernous sinus so that such a dissection can be quite bloody and the bleeding difcult to control. Endoscopic Anatomy of the Infratemporal Fossa Once the bone overlying the posterior wall of the maxil- lary sinus has been removed, the pterygopalatine fossa and infratemporal fossa are seen (Fig. These fossae are covered by periosteum and the contents are exposed by removing the periosteum. Once the fat has been removed the underlying Bone has been removed at the lateral recess (between the vidian nerve and maxillary artery and muscles of the infratemporal fossa can the maxillary division of the trigeminal nerve).

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However generic trileptal 600mg free shipping, in Ebstein anomaly purchase trileptal 600 mg line, multiple regurgitant jets are common and measuring the width of each vena contracta may not be useful generic trileptal 300mg with mastercard. Many of the published society valve guidelines are not directly applicable to smaller patients with Ebstein anomaly. In smaller patients, vena contracta diameter <10% of the annulus diameter is considered mild. Vena contracta diameter >25% to 30% of the annulus dimension is classified as severe. The density of the tricuspid regurgitation spectral Doppler signal may also be useful. The tethering and multiple origins of regurgitant flow dramatically decrease the chance for successful monoleaflet repair, and a tricuspid valve replacement was performed. Although a monoleaflet repair was not possible, if this patient presented today the amount of leaflet tissue present suggests that a cone reconstruction would be possible, although each individual fenestration would need to be closed as a part of the repair. Nongeometric measures (such as the myocardial performance index) and qualitative grading of myocardial dysfunction are used in most clinical situations. The functional orifice is also the origin of a single broad jet of regurgitation (right, red arrow). This jet begins near the right ventricular outflow tract and is oriented in inferiorly and toward the diaphragm, near the inferior vena cava–right atrial connection. Echocardiography adequately displays all the anatomical and functional features needed to make clinical decisions in these patients. Cardiac magnetic resonance imaging and the assessment of Ebstein anomaly in adults. A rare circumstance for the use of cardiac catheterization is in the infant with associated critical pulmonary valve stenosis requiring balloon valvuloplasty. Cardiac catheterization is rarely needed in adolescents and adults with Ebstein anomaly. In that case, pulmonary valve competency and low pulmonary vascular resistance are prerequisites. Pulmonary arterial pressure and pulmonary arteriolar resistance usually are normal in patients with Ebstein anomaly. The need for inotropic support is rare but it is used in1 those patients with severe congestive cardiac failure. Several large centers have adopted a management strategy that all patients with Ebstein P. Neonates with Ebstein anomaly can be difficult to manage due to increased pulmonary vascular resistance. This leaves the patient extremely cyanotic due to right-to-left shunting across atrial level defects. The1 use of inhaled nitric oxide may also assist in the reduction of the pulmonary vascular resistance (95). As the pulmonary vascular resistance drops and antegrade flow across the pulmonary valve occurs, the prostaglandin infusion can be weaned. Cyanosis will steadily improve due to less tricuspid regurgitation and less right-to-left shunt at atrial level. In the rare cases of neonates with pulmonary valve regurgitation, a “circular circulation” is established which also increases cyanosis and these patients have a poor outcome. The pulmonary regurgitant stroke volume contributes to the tricuspid regurgitation. Principles of Surgical Management for Ebstein Anomaly The goals of surgery for Ebstein anomaly are: 1. However, those with the most severe forms with persistent cyanosis or important associated lesions will require intervention. Palliative tricuspid valve patch closure with a fenestration (Starnes procedure) in conjunction with a systemic-to-pulmonary artery shunt have been successful in neonates (96). However, early mortality in neonates requiring surgery for Ebstein anomaly remains high (25%). In that approach, the tricuspid valve is repaired and the atrial septum is partially closed. This technique utilizes a monocusp approach based on a satisfactory anterior leaflet (97). The complexity of the contemporary “cone reconstruction” (described below) limits its feasibility in most ill neonates. Postoperative care in neonates is challenging, and delayed sternal closure is common. A biventricular approach was performed in 25 neonates with tricuspid valve repair in 23 patients. Despite high early mortality these results have become a benchmark for management of a very difficult group of patients. The decision to proceed with a biventricular repair versus a single-ventricle strategy is largely determined by institutional experience. When tricuspid valve anatomy is appropriate for repair, a biventricular approach is preferred. In patients with anatomic pulmonary valve atresia or poor tricuspid leaflet anatomy, the single-ventricle strategy is favored. With the improved results of the biventricular and single-ventricle approaches, cardiac transplantation rarely is performed in the current era. The availability of smaller ventricular assist devices and advances in neonatal extracorporeal membrane oxygenation provide mechanical support options in the perioperative period for these infants. In those younger than 60 years old, valve repair rather than valve replacement is preferred. In the current era, it is rare for a child or young adult to require valve replacement for Ebstein anomaly. A: Adherent segments of tricuspid valve tissue being separated from the anatomic annulus and the underlying right ventricular myocardium. This tissue is used to create a cone, often attaching the anterior leaflet to the remnants of the septal leaflet (see suture line, C). Once the cone is created, the base is attached to the atrioventricular junction, restoring the hinge points to a nondisplaced position (C). When dilated, thin, or significantly dyskinetic, the atrialized right ventricle can be reduced in size by either elliptical resection or plication (C). The annuloplasty reduces the size of the intraventricular junction to what is appropriate to the size of the reconstructed cone. Valve replacement is reserved for the most advanced anatomic abnormalities that include the following: complete absence of the septal leaflet, heavy muscularization of the anterior leaflet, marked tethering of the leaflet leading edges, or severe tethering of the anterior leaflet with minimal delamination (104).

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Atrial tumors create mitral or tricuspid valve stenosis by a to-and-fro motion through the valves (137 cheap 150mg trileptal fast delivery,138) buy discount trileptal 600mg online. Typically purchase 300 mg trileptal amex, these large pedunculated tumors advance through and obstruct the atrioventricular valve during diastole and are expelled retrogradely into the atrium during systole. Large left atrial myxomas obstruct pulmonary venous inflow and flow across the mitral valve, resulting in signs and symptoms of pulmonary edema, pulmonary arterial hypertension, and low cardiac output (137,138,162). Ventricular ischemia and dysfunction may develop when cardiac output is significantly impeded (144). Right-sided heart failure and low cardiac output occur when right atrial tumors impede systemic venous inflow and obstruct flow across the tricuspid valve (137,138,139,140,141). Myxomas may mimic neonatal cyanotic heart disease when obstructive right-sided tumors cause right-to-left shunting at the atrial level (139,140,141,142). Sudden death has been reported when large tumors completely obstruct either the mitral or tricuspid valve (139,140). Large calcified tumors have been associated with complete valve destruction (143). Semilunar valve obstruction can occur when large myxomas are inferiorly positioned within the atrium and are attached to a long tumor pedicle (163). This allows atrial tumors to prolapse through the atrioventricular valve and ventricular outflow tract, resulting in diastolic semilunar valve stenosis. Pedunculated ventricular myxomas (164) also can cause systolic aortic or pulmonary outflow tract obstruction (29,142,143,163,165). Auscultatory findings of left atrial myxomas are consistent with atrioventricular valve stenosis and insufficiency (137,138,143). A middiastolic murmur and low-pitched tumor plop are characteristic findings (137,138,166); however, absence of the murmur may occur with severe obstruction (124). Right atrial tumors have nonspecific systolic and diastolic murmurs mimicking the Ebstein anomaly or tricuspid valve stenosis and regurgitation (137,138,139,140,141). When atrial myxomas obstruct the atrioventricular valves, the patient may experience dyspnea, dizziness, or syncope when sitting or standing, with alleviation of symptoms on lying down. In the neonate, positional symptoms consist of feeding difficulty and irritability while sitting (141). When tumors obstruct the semilunar valves, patients experience symptoms while bending forward or lying down, with relief of symptoms when standing (164). Peripheral emboli occur in >70% of pediatric patients with myxomas (144), including newborns in whom embolization has been reported to have occurred in utero (139). Emboli are related to fragmentation of tumor substance or embolization of thrombi adherent to the tumor external surface (138,167). As expected, left-sided tumors are associated with systemic (168) and right-sided tumors with pulmonary arterial embolization (139,141). Bilateral atrial myxomas have been reported to cause both pulmonary and systemic arterial emboli (149), and right-sided tumors have been associated with paradoxical emboli in patients with atrial septal communications (139,141). Systemic embolization can occlude coronary, pancreatic, thyroid, adrenal, renal, splenic, cerebral, and extremity arteries, resulting in infarction of corresponding tissue (87,149,162,167). Symptoms related to peripheral emboli may not become apparent until months to years after removal of the primary myxoma (146,149,153,167). This temporal delay has been attributed to recurrence of nonmalignant myxomas at the same or other cardiac sites (146). The potential for recurrence appears to be associated with inadequate resection (169,170,171,172) or totipotent multicentricity (173). Peripheral arterial aneurysms also have been diagnosed years after initial embolic events. Small embolic myxoma fragments may continue to grow, undergo malignant transformation, and invade and replace the medial arterial wall, resulting in aneurysm formation (137,149,153,167). Constitutional symptoms, the third major component of the clinical triad, occur in ≤65% of pediatric patients with myxomas (144). Persistent fever, malaise, weight loss, arthralgias, and myalgias may be present months before tumor diagnosis (137,138,143,144,147,168,174). Laboratory studies show anemia, thrombocytopenia, elevated sedimentation rate, and elevated gamma globulins. Patients have been diagnosed as having acute rheumatic fever, chronic rheumatic carditis, subacute bacterial endocarditis, septicemia, myocarditis, and other collagen vascular disorders (141,142,143,144,145,146,147,166,168,174,175,176). These constitutional findings have been attributed to a diffuse immunologic response to the primary tumor or to tumor emboli (137,141). Recent reports suggested that these systemic abnormalities are secondary to secretion of interleukin-6 and frequently resolve with tumor resection (176,177,178). Interleukin-6 is associated with the synthesis of several proteins that contribute to the acute-phase response and corresponding constitutional signs and symptoms (179). Right ventricular hypertrophy may be due to pulmonary valvar obstruction, pulmonary arterial hypertension secondary to pulmonary emboli, or pulmonary venous hypertension from left atrial tumors (138). Bundle branch block, repolarization abnormalities, or severe conduction abnormalities, commonly seen with intramural rhabdomyomas and fibromas, are rarely seen with myxomas. The chest radiograph may be normal (141,151) or may demonstrate cardiomegaly with pulmonary edema (137,138,141,143). Right-sided myxomas show right atrial and right ventricular enlargement (151,163). The mainstay in the diagnosis of cardiac myxomas is 2-D Doppler echocardiography (137,145,151,163,165,168,180,181). In a retrospective review, myxomas were diagnosed in 37% of patients before, and in 90% of patients after, the advent of echocardiography (182). The virtual pathognomonic finding of an atrial myxoma is that of a large pedunculated tumor mass traversing through the atrioventricular valve in a to-and-fro motion (Figs. In some patients, however, the tumor may not appear to prolapse into the ventricle either as a result of a short pedicle or because of its large size (165,180). Single ventricular (165), biatrial (145), and simultaneous atrial and ventricular myxomas (151) have been diagnosed accurately by this technique. Similar to rhabdomyomas and fibromas, pericardial effusions have not been reported with atrial myxomas. Surgical results have been excellent (137,138,143,144), with resolution of associated symptoms (137,143,183). Surgery includes wide resection at the point of attachment of the pedicle to the heart. Since attachment most commonly occurs at the fossa ovalis, removal of large segments of the atrial septum is often done. Careful examination of the entire heart is necessary to remove concurrent sites of myxomatous tissue. The use of echocardiography to facilitate a surgical approach has been proposed (184) by preoperatively defining tumor size, location, point of attachment, and the presence of concurrent site involvement. Patients require continual reevaluation for recurrence of disease and for later development of peripheral arterial aneurysms (137,143,146,149,153,167,182). The approximate incidence of recurrence is 4% to 7% in most large series (169,171,185,186).