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During a 7½-year period, 102 patients underwent pericardiectomy in the Emory University Affiliated Hospitals for a wide variety of pericardial disease. Seventy-six patients had predominantly effusive pericardial disease, and 26 patients had constrictive pericarditis. Nineteen cases of constrictive pericarditis developed in patients who had undergone previous open-heart operations. Hospital mortality at six weeks was 8.8%. The surgical approach was a left anterior thoracotomy in 72 patients; median sternotomy in 26 patients; and a subxiphoid approach in 4 patients. Only 2 patients required cardiopulmonary bypass. A detailed discussion of each subgroup of patients with pericardial disease requiring pericardiectomy is given.

The internal mammary artery is a dynamic conduit used for myocardial revascularization in which potential exists for spasm as well as for vasodilation. This study investigated vasodilator drug effects on the mammary artery using nitroprusside and nitroglycerin in vitro to measure the inhibition of contraction of human internal mammary artery and in vivo to examine blood flow through a canine mammary artery. In the in vitro study, ring segments of human internal mammary arteries were suspended on strain gauges in muscle baths containing 37 °C Krebs solution for measurement of isometric tension in vitro. Arterial contraction was stimulated with 70 mMpotassium and 10 μM norepinephrine, and inhibition of contraction by vasodilators was measured. Nitroprusside was more potent and effective than was nitroglycerin in inhibiting potassium and norepinephrine contraction. The in vivo study utilized a canine (n = 8) right heart bypass preparation that allowed precise control of cardiac output, blood pressure and heart rate, which were maintained constant. The internal mammary artery graft and the saphenous vein graft perfused the same coronary artery bed. Electromagnetic flow probes measured graft flow (with the other graft occluded) before and after 15 min of drug infusion (1 μg/kg per min). Nitroglycerin significantly increased mammary artery flow 36 ± 13%, whereas nitroprusside significantly decreased it 12 ± 2%. Saphenous vein grafts responded differently; graft blood flow decreased with nitroglycerin and increased with nitroprusside. Thus, although nitroprusside was more effective than nitroglycerin in inhibiting mammary artery contraction in vitro, it decreased internal mammary artery graft flow measured in vivo. Nitroglycerin had the opposite effect, increasing mammary graft flow. In addition, saphenous vein grafts responded differently from the mammary artery to vasodilator administration. These divergent findings in the in vivo canine and in vitro human studies may have resulted from the effects of the vasodilators on the regional vasculature. However, the in vivo response in canine vessels may not necessarily predict the in vivo response of human vessels to vasodilators.

A patients is described with postinfarction ventricular septal defect in whom the perforation was successfully closed within 24 hours of septal rupture. This presents the second such case reported in the literature. Adjunctive measures consisting of myocardial revascularization and intracoronary infusion of mannitol were thought to be important in the successful outcome of the operative procedure. The importance of complete preoperative cardiac catheterization with coronary arteriography is stressed. The theoretical role of endothelial and myocardial cellular edema as a cause of depressed myocardial function immediately following an ischemic insult is proposed as a practical consideration in the high mortality associated with this condition. Methods used to prevent or reverse such cell swelling are described. The details of the operation in which viable ventricle myocardium was used to fill the septal defect are presented.

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.

Controversy exists over the surgical approach for thymectomy for myasthenia gravis. Opinion is divided between transcervical thymectomy and transsternal thymectomy performed through a median sternotomy. A technique that combines the advantages of a small, cosmetic T incision with good visualization through a partial sternotomy is presented. We have utilized this technique in more than 35 patients during the past ten years with excellent results.

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Rehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are; self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CECAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from CAB alone.

Between June, 1982, and July, 1983, 6 children with partial anomalous pulmonary venous connection to the middle or high segment of the superior vena cava (SVC) underwent repair of the anomaly by division of the SVC proximal to the site of entry of the anomalous pulmonary veins. Continuity between the cephalad end of the SVC and the right atrium was established by direct anastomosis to the right atrial (RA) appendage or by creation of a pedicle conduit of RA appendage, RA free wall, and pericardium. The anomalous pulmonary veins remained in situ on the lower segment of SVC, blood being directed to the left atrium through an atrial septal defect by a pericardial patch placed within the right atrium well away from the sinoatrial node, anomalous pulmonary veins, and cavoatrial junction. All children have survived, remain in normal sinus rhythm, and have no evidence of vena caval or pulmonary venous obstruction. Follow-up cardiac catheterizations, angiocardiograms, and Holter recordings support the efficacy of this technique as an alternative in the management of anomalous pulmonary veins joining the SVC well above the cavoatrial junction.

This report details our experience in 40 patients with benign strictures of the esophagus who underwent colon (or gastric) interposition with our without esophageal resection between 1972 and 1980. There were 23 men and 17 women ranging from 5 to 76 years old. Twenty-seven patients had fibrotic strictures secondary to reflux esophagitis including 12 after failure of antireflux procedures; 4 had caustic strictures; 3 had a Barrett's esophagus; 2 had systemic candidiasis; 2 had scleroderma; and in 2 the etiology was undetermined. the right colon was used in 27 patients, the left colon in 4, the transverse colon in 1, and the jejunum in 1. In 7 patients the stomach was employed because of vascular insufficiency of the colon. Three surgical approaches were utilized. Manometric studies were done post-operatively in 10 patients. Complications occurred in 7 patients: cervical leaks, 4; reflux colitis, 2; and a late cervical stricture, 1. There were 4 deaths, only 1 of which was related directly to technique. This report summarizes the beneficial effect of right colon interposition for long esophageal strictures. Its vasculature is adequate, and it functions properly to propel food into the stomach irrespective of the peristaltic orientation.

The records of 176 patients admitted to Grady Memorial Hospital over a 10-year period with a history of ingestion of corrosive material were reviewed. Esophagoscopy was performed in 168 patients an average of 15 hours after ingestion. In 94 patients, no esophageal burn was found. Seventy-four others had injury of the esophagus of varying degree; 3 of these had no evidence of oropharyngeal burn. The patients with esophageal injury were treated with steroids for two weeks and antibiotics for 5 days. No complications resulted from esophagoscopy or steroid therapy in any patient. Stricture did not develop in any of the patients in whom esophagoscopy was negative. Documented stricture occurred in 29 patients with esophagoscopic evidence of esophageal burns, 7 of whom did not respond to periodic esophageal dilation and subsequently underwent esophageal bypass. Three patients had symptoms and signs of gastric perforation on the first, sixth, and eighth days after ingestion, respectively, and at laparotomy all of them were found to have severe gastric injury. One of these patients died on the postoperative day 28; this was the only death among all patients seen with history of ingestion of corrosive material. This study suggests that with early esophagoscopy, approximately 55% of patients who ingest corrosive material can be spared the agony and prolonged treatment of possible esophageal injury. Appropriate management will result in preservation of the esophagus in most patients.

From January, 1970, through December, 1984, nineteen infected or eroded pacemaker units were reimplanted in 17 patients. Characteristics of the patients, types of infecting organisms, surgical management, and complications are described. Optimal treatment of the infected generator pocket requires explantation of the generator unit with utilization of the in situ leads for pacing by an external-demand pacemaker unit. The generator unit is sterilized, and new leads are placed with relocation of the pocket. The old leads are then removed. This technique has been used safely and with excellent results for the past fourteen years.

Porcine cardiac xenografts were used for cardiac valve replacement in 1,093 patients. Hospital mortality for aortic valve replacement (AVR) was 3.7%; for mitral valve replacement (MVR), 7.8%; and for AVR + MVR, 4.7%. Total follow-up was 2,036 patient-years; maximum, 7.3 years; and mean, 1.89 years. Actuarial survival (+/- standard error of the mean) for AVR was 84% +/- 2% at 56 months; for MVR, 84% +/- 3% at 56 months; and for AVR + MVR, 86% +/- 4% at 30 months. Nonfatal thromboembolism occurred in 8 of 1,030 patients (0.78%). Anticoagulation was not routinely employed. Fifty hospital survivors (4.8%) experienced valve dysfunction; 18 of the survivors (1.7%) died; and 32 of the survivors (3.1%) underwent reoperation. The rate of dysfunction increased slowly until the sixth year when an increased rate was observed (p less than 0.0001). Patients less than 34 years old had a higher incidence of dysfunction (p less than 0.01). Thirty-two hospital survivors (3.1%) underwent explantation of the porcine valve for late dysfunction. Valve dysfunction secondary to endocarditis and paravalvular leak occurred early, while leaflet deterioration or thrombosis was more gradual in onset and was noted later. The porcine valve has functioned well for 1 to 7 years with a low incidence of valve related morbidity and mortality without routine anticoagulation in patients older than 34 years of age.

From 1974 through 1977 when our hospital mortality for aortic valve replacement and myocardial revascularization was 3.5% and 1.1%, respectively, hospital mortality for mitral valve replacement (MVR) was 8.3% (13/156)—as high as 14.9% in 1976. Transverse midventricular disruption (TMD) was present in 7 of 10 patients on whom an autopsy was done and was clinically diagnosed in 3 others without postmortem examination. Transverse midventricular disruption presented as refractory myocardial failure immediately on termination of bypass or later (1 to 5 days) after an initial period of good hemodynamics. It appeared to result when volume loading or afterload pressure was returned to the untethered ventricle after MVR performed with potassium-induced, cold cardioplegia and ischemic arrest. Operative techniques were modified to preserve a portion of the mitral suspensory mechanism, to extend the reperfusion interval following cardioplegia and ischemic arrest, and to control strictly ventricular volume and pressure loading following bypass. By utilizing these methods, TMD was avoided from 1978 through 1982, and hospital mortality for MVR was 3.7% (9/241). The improved hospital mortality and avoidance of TMD did not result from patient selection. Allowing adequate time for recovery of the myocardium after cardioplegia plus ischemic arrest prior to ventricular loading, preservation of mitral suspensory function, and strict control of preload and afterload pressures have been effective in lowering hospital mortality for MVR and have eliminated TMD in a 5-year period.

A new permanent epimyocardial Medtronic 4951 “stab-in” or “fishhook” pacing electrode was implanted in 16 children. Identical technique, with particular attention to the direction of the coronary circulation, was utilized to implant the leads. There were 10 atrial implantations (5 active, 5 redundant) and 18 ventricular implantations (15 active, 3 redundant). Pacing modes were VVI (12), VDD (1), DVI (2), and DDD (1). Experience with the lead covers 280 patient months (3 days to 21.8 months, mean 14 months). Patients were allowed monthly via telephonic transmission. With the exception of the single patient who expired three days after implantation, each patient has returned for follow-up analysis including chronic threshold determinations using the programming capabilities of the pulse generators. Only one lead required more than the minimum obtainable voltage output from the pulse generator to effect capture. No other lead required more than 5.0 volts at 0.5 ms pulse width. There have been no lead fractures or dislodgements. In this evaluation the Medtronic 4951 lead performed well in both atrium and ventricle in a group of children with diverse cardiac pathology. The small diameter of the lead and the low profile of the electrode are advantageous for use in pediatric patients.

A congenital coronary artery anomaly influenced operative management of 21 children (34 operations) during a recent 8-year interval. This group represented 1.3% of cardiothoracic operations performed. Survivors included 5 of 10 children having correction of the left coronary artery from the pulmonary artery and 11 children having correction of intracardiac defects associated with major coronary arteries crossing the right ventricular outflow tract. Two children survived primary repair of injured major coronary arteries. Isolated coronary artery anatomy must be considered during management of intracardiac defects. Intraoperative injury to a major coronary artery requires meticulous repair.

Unstable angina pectoris encompasses a broad spectrum of clinical subsets with varying prognoses. It is impossible to identify which patients have severe obstructive coronary disease and, therefore, coronary arteriography should be employed. In patients with severe obstructive disease, coronary bypass surgery has resulted in dramatic symptomatic improvement and has improved the survival of patients with 2-and 3-vessel disease, as compared to medically treated groups. Aggressive preoperative medical management coupled with improved anesthetic and surgical techniques have aided in the salvage of these unstable patients.

The clinical situation of heterogeneous cardioplegia was simulated in a canine model by temporary ligation of the circumflex coronary artery during a three-hour interval of cardioplegic arrest. Nifedipine and lidoflazine, administered prior to aortic clamping, were evaluated as adjuncts to cold (2 degrees C) crystalloid cardioplegia. Assessment was made of regional function (sonomicrometer systolic shortening) and of global function by measuring left atrial (LA) pressure at constant cardiac output (CO), aortic pressure, and heart rate, and by measuring stroke work at constant LA pressure, aortic pressure, and heart rate. Among 14 control dogs, only 7 could achieve a CO of 5 liters per minute following cardioplegic arrest. Left anterior descending coronary arterial systolic shortening recovered to only 86% of prearrest values (p less than 0.05), circumflex coronary arterial systolic shortening recovered only 28% (p less than 0.01), stroke work recovered 59% (p less than 0.01), and LA pressure was 6.7 mm Hg higher (p less than 0.01) than prior to cardioplegic arrest. Lidoflazine provided no statistically significant benefit in these animals (N = 4). However, dogs given nifedipine (N = 6) had very little change in left anterior descending coronary arterial systolic shortening (99% recovery), stroke work (93% recovery), and LA pressure (delta = 0.4 mm Hg). None of these changes was statistically significant. There was some deterioration in circumflex coronary arterial systolic shortening (56% recovery; p less than 0.05). All 6 dogs given nifedipine achieved a CO of 5 L/min following cardioplegic arrest. Clinical cardioplegia is typically heterogeneous cardioplegia. Calcium-channel blockade appears to be useful in this situation.

The patient who needs a pneumonectomy but has an infected pleural cavity faces the probability of an empyema of the pneumonectomy space. Balanced drainage of a contaminated space may avoid this very serious complication. A patient with obstructing bronchogenic carcinoma associated with distal parenchymal suppuration and empyema is discussed. A pneumonectomy with balanced drainage of the pleural space was performed. After three weeks the mediastinum was stable, and daily irrigation of the space with antibiotic solution was begun. Following fourteen days of irrigation, the cavity was filled with antibiotic solution and closed. Follow-up has shown no subsequent space problems or infection. Balanced drainage is a useful method of dealing with a contaminated pneumonectomy space.

Myopotential inhibition of unipolar demand pacing systems has been shown to be a frequent occurrence in adults with transvenous pacing systems in which the pulse generators are implanted adjacent to the pectoralis muscle. To evaluate this problem in children, most of whom have epimyocardiol systems and abdominal wall generator implants, 50 patients underwent electrocardiographically monitored exercise nnd 24-hour ambulatory electrocardiograph monitoring. Patients' ages at the time of study ranged from less than one year to 18 years, and weights ranged from less than 5 kg to 63 kg. Sixteen different models of pulse generators from five manufacturers were involved. Pacing modes were VVI. DVI. AAI, VDD, and DDD. Forty-seven patients had epimyocardial systems. None of the patients was symptomatic as a result of myopotential inhibition. Oniy three patients (6%) had any evidence of myopotential inhibition and all three demonstrated this inhibition on both monitored exercise and ambulatory electrocardiograph. The inhibition was eliminated by reprogramming the sensitivity levels of the three generators without compromising R-wave sensing. Thirteen of the remaining 35 patients with mulliprogrammable generators had induction of myopotential inhibition when exercised after temporary programming to maximal sensitivity settings. Myopotential inhibition of unipolar demand pacing appears to be less frequent and less problematic in the pediatric population, even though they are physically quite active. It is not clear whether this is a function of patient size or the abdominal wall position of the pulse generator. Because our three cases of pacing inhibition occurred in larger children, we currently recommend repeated testing for myopotential inhibition as the patients continue to grow.

During the past ten years, 20 patients with acute penetrating tracheal injury (15 cervical and 5 thoracic) have been treated at Grady Memorial Hospital. Ten of the 20 patients had other major associated injuries: 6 had esophageal wounds, 5 had arterial injuries, and 2 had additional wounds. In the first 5 patients treatment of the tracheal injuries consisted of tracheostomy alone. Later on, the tracheal wounds were managed according to type, site, size, and the type of other organ injury. Repair of the tracheal wound and tracheostomy were done in 3 patients, repair of the tracheal wound and temporary tracheal intubation in 4 patients, tracheocutaneous stoma in 1 patient, temporary tracheal intubation alone in 4 patients, and observation alone in 3 patients. Seventeen patients recovered from their injuries and 3 died from sepsis, respiratory insufficiency, or cerebrovascular accident. All 3 deceased patients had other major injuries. This experience suggests that the treatment of penetrating tracheal injury should depend upon the type, size, and site of the wound and the type of coexistent injury to other organs, and that primary repair of the tracheal wound can be carried out in the majority of the patients.

One hundred and fifty-two patients age 70 years or more underwent aortic valve replacement (AVR) at Emory University Hospital between July 1, 1974 and July 1, 1982. Of these, 98 had isolated AVR (elderly AVR group) and 54 had concomitant coronary artery bypass grafts (elderly AVR/CABG group). Results of surgery in these patients were compared to results in patients aged 20 to 69 years operated on in the same period (young AVR/CABG groups). Comparative descriptors with statistically significant differences included a higher incidence of both stable and unstable angina in patients undergoing concomitant CABGs ; less cardiomegaly in the young AVR/CABG group; less hypertension, a higher incidence of pure aortic regurgitation, and less frequent use of inotropes in the young AVR group; a higher perioperative stroke rate in elderly AVR/CABG patients; a higher perioperative psychosis rate in patients having CABGs regardless of age; and a longer postoperative hospital stay for the elderly patients. There were no significant differences between the four groups for the following descriptors: sex ratio; history of congestive heart failure; the presence of atrial fibrillation; left ventricular end diastolic pressure, ejection fraction and contractility; number of diseased coronary arteries; number of vessels bypassed; use of the intra-aortic balloon pump; re-exploration for hemorrhage; perioperative myocardial infarction rate; and major wound infection rate. Operative mortality was 5.1% for the elderly AVR group, 5.6% for the elderly AVR/CABG group, 1.9% for the young AVR group, and 5.1% for the young AVR/CABG group (p = NS). Overall, hospital mortality was 3.3%. Actuarial survival curves for all elderly versus all young patients showed no significant difference. The curve for elderly patients compares favorably with the actuarial survival of the same age group in the general population. Actuarial survival curves for the four subgroups did not differ significantly when compared at a follow-up of 36 months after surgery. We conclude that AVR with or without concomitant CABGs can be performed in elderly patients with an acceptably low mortality and morbidity, and the postoperative survival compared favorably both with younger patients and with the general population of the same age.

Sternal osteomyelitis and mediastinitis caused by Pseudomonas cepacia developed in a patient undergoing coronary artery bypass two weeks after the operation. P. cepacia bacteremia from a contaminated pressure transducer had preceded and probably caused the chest infection. While other authors have suggested that postoperative sternal osteomyelitis and mediastinitis result from local wound contamination, this case suggests the importance of bacteremia as a cause of such gram-negative infections. Since patients undergoing open-heart operation are exposed to many sources of bacteremia, prevention of severe postoperative chest infections may depend in large part on careful preoperative evaluation of each patienc antibiotic regimens, and, as shown in this patient, on very thorough periodic review of equipment sterilization and intravascular monitoring practices.

A patient with W-P-W syndrome (type A) and disabling supraventricular tachycardia was studied with epicardial mapping prior to surgical interruption of the circus pathway. Analysis of the delta vector and results of the epicardial mapping strongly suggested aberrant pathway located very posteriorly and crossing the atrioventricular sulcus in or adjacent to the interventricular septum. A circus movement responsible for the supraventricular tachycardia was felt to be a mechanism of antegrade A-V conduction and retrograde accessory bundle conduction. Attempts to interrupt the aberrant pathway primarily were unsuccessful, and surgical A-V block was performed. An epicardial demand pacemaker was inserted as a safety feature. Since the operation the patient has been free of supraventricular tachycardia. The postoperative electrocardiograms demonstrated antegrade accessory pathway conduction, but neither antegrade nor retrograde A-V conduction. Failure to interrupt the accessory pathway after incision of the entire right posterior A-V sulcus supported a location with, or to the left of, the atrioventricular septum for the pathway. This case, with the recent results of others, adds to the further understanding of accessory pathway location in W-P-W syndrome (type A).

In 1933, Kartagener reported an unusual triad: situs inversus, bronchiectasis, and sinusitis. This is a report of 15 cases seen by the authors. Seven of these cases occurred in four families with multiple siblings showing one, two, or all three components. There was one set of identical twins. Bronchiectasis occurs more frequently in patients with situs inversus. This is reported 12 per cent-25 per cent as opposed to 0.3 per cent-0.5 per cent in general population. The etiology and relationship of bronchiectasis in situs inversus is probably congenital, but it is difficult to determine the factor involved. Management of these cases did not vary from usual treatment of suppurative tracheobronchial and paranasal difficulties. Pulmonary resection was done in five of these cases.

Achalasia of the esophagus is characterized by lack of neuromuscular coordination, which results in an absence of normal peristalsis in the body of the esophagus and a failure of relaxation of the lower segment. It is a frequent cause of esophageal obstruction. Symptoms of achalasia include dysphagia, regurgitation (nocturnal overflow), substernal discomfort, recurrent pulmonary infection, and weight loss. The diagnosis of achalasia is established by esophagoscopy, x-ray examinations (routine posterioanterior and lateral views), barium swallow and cinefluoroscopy, and esophageal motility studies. Treatment consists of bougienage, forceful dilation, and Heller esophagocardiomyotomy.

Eleven patients were operated upon for severe aortic insufficiency secondary to bacterial endocarditis. In 6 patients, satisfactory medical treatment was accomplished well before surgery. In 5, intractable congestive failure and a critical clinical situation necessitated surgery while medical treatment was in progress. There were 10 survivors (91 per cent) and 1 death (9 per cent) in this group of patients followed up from three months to four years. The organisms responsible, their routes of entry and pre- and postoperative antibiotic regimens are presented. All patients exhibited one or more leaflet tears or perforations. In the acutely ill group, two aortic ring abscesses and one high ventricular septal defect were encountered. A ball valve prosthesis was used for aortic valve replacement in every instance. Teflon felt grafts were employed to replace the aortic perforations in the patients with abscess formation and to close the ventricular septal defect. The surgical results are most encouraging since death was considered imminent in 5 patients and inevitable in all patients without operative intervention.

The first two long-term survivors treated surgically for cardiac rupture after myocardial infarction have been followed up for one and three years. Acute electromechanical dissociation in a patient previously without serious hemodynamic problems after a myocardial infarction is the cardinal feature, allowing the diagnosis of most salvageable cases. Immediate and, if necessary, continuous pericardicentesis, volume loading, and the administration of inotropic amines may give enough time for surgical intervention in some patients.