870 Brief Communications September 1991 American Heart Journal months later, the patient developed significant congestive Isolated partial anomalous pulmonary heart failure, and a loud mitral regurgitation murmur was noted. The patient then had several admissions for decom- pensated congestive heart failure despite treatment with digoxin, diuretics, and afterload-reducing agents. At 6 months after the procedure the patient had a repeat cardiac catheterization, which demonstrated severe (4+) mitral regurgitation, He underwent mitral valve replacement with a Carpentier-Edwards prosthesis (Baxter Healthcare Corp., Edwards Division, Santa Ana, Calif.) and at surgery it was noted that both papillary muscles were very fibrotic, especially the posteromedial papillary muscle. He died of sepsis 3 weeks later. These cases demonstrated the occurrence of cryoabla- tive-induced severe mitral regurgitation in map-guided VT surgery. Both of these patients had their earliest sites of VT mapped to areas on the papillary muscles. One of them (JL) probably had a damaged posteromedial papillary muscle from myocardial infarction and its resultant mild mitral regurgitation, which was worsened after cryoablation of the anterolateral papillary muscle during surgery. In our insti- tution, with a relatively extensive experience in this type of surgery (128 operations performed since 1979), this com- plication has an overall incidence of 5.3 % during the 6 % - year follow-up. However, of the 38 patients, only 24 had cryoablation, and of those only 11 had the application at or near the papillary apparatus. Thus the incidence of late mitral regurgitation in patients receiving cryosurgical ma- nipulation of the mitral apparatus may actually be rela- tively high (18 % in this series). In the three large published series, , lb3 however, only one patient was reported to require reoperation for mitral regurgitation. It has been suggested that in patients undergoing VT surgery with papillary muscle scarring, papillary muscle resection with mitral valve replacement is necessary to decrease failure owing to arrhythmia recurrence or mitral regurgitation.4 Our expe- rience with patient JL is certainly in agreement with this recommendation. In summary, severe mitral regurgitation can occur in patients undergoing map-guided VT surgery with cryoablation involving the regions of the papillary muscles, especially if there is prior papillary muscle dam- age. Therefore surgically-induced mitral regurgitation should be in the differential diagnosis of patients who de- veloped severe heart failure after surgery. REFERENCES 1. Swerdlow CD, Mason JW, Stinson EB, Oyer PE, Winkle RA, Derby GC. Results of operations for ventricular tachycardia in 105 patients. J Thorac Cardiovasc Surg 1986;92:105-13. 2. Miller JM, Kienzle MG, Harken AH, Josephson ME. Sub- endocardial resection for ventricular tachycardia: predictors of surgical success. Circulation 1984;70:624-31. 3. DiMarco JP, Lerman BB, Kron IL, Sellers TD. Sustained ventricular tachyarrhythmias within 2 months of acute myo- cardial infarction: results of medical and surgical therapy in patients resuscitated from the initial episode. J Am Co11 Car- diol 1985;6:759-68. 4. Kron IL, DiMarco JP, Lerman BB, Nolan SP. Resection of scarred papillary muscles improves outcome after surgery for ventricular tachycardia. Ann Surg 1986;203:685-90. venous connection: Echocbdiographic diagnosis and a new color Doppler method to assess shunt volume Rajendra H. Mehta, MD, Suresh P. Jain, MD, Navin C. Nanda, MD, Frederick Helmcke, MD, and Rajatsubhra Sanyal, MD. Birmingham, Ala. Partial anomalous pulmonary venousconnection is a rela- tively uncommoncongenital anomaly with an incidence of about 0.7% in routine autopsies.’ It is often associated with an atria1 septal defect, especiallyof the sinus venosus type. The isolated form of the anomaly with an intact atrial sep- tum is even more uncommon. Accurate diagnosis and mea- surement of the left-to-right shunt are important consid- erations in deciding the course of managementin these patients and are usually accomplished by cardiac catheter- ization and angiocardiography.Although both two-dimen- sional and pulsed Doppler echocardiographyz 3have been usedin the identification of this entity, a major limitation hasbeen the inability to make a definitive diagnosis in the adult patient in whom the acoustic window is often much smaller than in children. The relatively recent develop- ment of transesophageal color Doppler echocardiography has overcome some of the limitations of the transthoracic technique. The close proximity of the transesophageal probe to the heart not only servesto obviate the acoustic window problem but alsoprovides superior quality images, sincea higher frequency transducer can be used for the ex- amination. The transesophageal technique has beenshown to supplement the transthoracic approach in the assess- ment of atria1 septal defects, aswell as in the detection of associated pulmonary venous connections.4 We have re- cently reported a new method for the assessment of left-to-right shunt volume in patients with an atria1 septal defect.5 In the present report we describethe extension of this method to calculate the left-to-right shunt volume in isolated pulmonary venous connection using both tran- sthoracic and transesophageal color Doppler echocardio- graphy. The usefulness and limitations of these technolo- gies in its diagnosis are also discussed. A 36-year-old man was diagnosedas having an atrial septal defect by cardiac catheterization at another hospi- tal about 4 years prior to his present admission because of increasedoxygen saturation in the right side of the heart and the fact that the catheter “easily” crossed into the left heart. Associated partial anomalous pulmonary venous drainage into the superior vena cava was also suspected because the oxygen saturation in this vessel wasfound to From the University of Alabama at Birmingham. Reprint requests: Navin C. Nanda, MD, University of Alabama at Birming- ham, Heart Station SWB/SlOZ, Birmingham, AL 35294. 414130499