Intrahepatic granulomatous arteriopathy.

one patient with tricuspid incompetence due to a ruptured papillary muscle after myocardial infarction. The higher incidence of left ventricular papillary muscle dysfunction reported (Heikkila, 1967) must be largely due to the higher incidence of left ventricular infarction observed by various workers (Wartman & Hellerstein, 1948; Zaus & Kearns, 1952). This patient had minimal dilatation of the tricuspid valve ring and the valves at post-mortem appeared competent. The neropsy impression is occasionally misleading as the valve ring may be larger during life, when the pressure in the right ventricle is increased. However, in this patient tricuspid incompetence persisted, although the clinical signs of heart failure were mild, although such failure as was present improved with treatment, and despite a decrease in heart size on the chest X-ray. This clinical course in conjunction with the autopsy findings make papillary muscle dysfunction the only tenable explanation for this patient's tricuspid incompetence. The mechanism of papillary muscle dysfunction in the left ventricle was reviewed by Burch, De Pasquale & Phillips (1963) and more recently by Raftery, Oakley & Goodwin (1966). The very prominent 'v' waves and 'y' descent in the jugular veins of this patient accord well with the left atrial pressure tracings found in patients with left ventricular papillary muscle dysfunction (Raftery et al., 1966). The right atrium in this patient was presumably normal before the sudden development of tricuspid incompetence and the venous pressure excursions were not damped because the atrium was still relatively uncompliant. Diagnosis of the cause of tricuspid incompetence is important. When due to papillary muscle dysfunction it should be amenable to surgical treatment as is mitral incompetence (Fluck et al., 1966). If this patient had survived with persistent tricuspid incompetence the question of prosthetic valve replacement would have been seriously considered.