Spina bifida: early antenatal diagnosis using amniotic fluid alpha-fetoprotein heterogeneity.

When seen in March 1977 she was well and managing her job. She had no signs of heart failure and the prosthetic sounds were normal. Four weeks later she suddenly deyeloped severe chest pains and was admitted. She was in fast atrial fibrillation and was hypotensive. On auscultation the opening and closing clicks of the prosthesis could be heard and there were coarse crepitations at the lung bases. An electrocardiogram showed changes of an inferolateral myocardial infarction, and a chest radiograph showed cardiomegaly with pulmonary oedema (see figure). A provisional diagnosis of coronary embolism and cardiogenic shock was made, and, despite conservative treatment, she died the following day, 21 hours after her acute collapse. At necropsy the Bjork-Shiley prosthesis was completely detached and lay free in the left atrium. The sutures were intact around the prosthesis ring although they were slightly loose. The edges of the mitral annulus were frayed but no thrombus or vegetations were present. Histological examination showed no evidence of infection or calcification, and there were no myxoid changes.