A 35-year-old woman with morbid obesity was admitted to Rush-Presbyterian—St Luke's Medical Center, Chicago, for a gastric plication procedure. She had a five-year history of intermittent palpitations, worsening over the preceding four months, associated with sharp precordial pains and dyspnea. Multiple abdominal surgical procedures had been done in the past, including several ovarian cystectomies, a total abdominal hysterectomy, and, one year prior to admission, a gastric plication that had failed. Two years prior to admission a subclavian catheter had been placed for three weeks of central hyperalimentation. An automobile accident six months prior to admission had resulted in superficial chest trauma.
The findings on physical examination were remarkable for obesity. Vital signs were normal, and a grade 2/6 systolic murmur was noted along the left sternal border, not changing with respirations. The jugular venous pulsations were normal. The lungs were clear, and no peripheral edema was noted. Rhythm strips and