This report describes one of the earliest cases of successful internal mammary artery grafting. A left internal mammary-right coronary artery titanium stent anastomosis was performed on Jan. 5, 1968, at Allegheny General Hospital. Repeated cardiac catheterization 2 weeks, 6 months, and 6 years after the operation showed a patent anastomosis. The patient survived over 17 years after the operation.

Preoperative plasma CEA levels were measured by radioimmunoassay for 149 patients with bronchogenic carcinoma. The data were used to determine the prognostic value of the CEA assay in these patients. The relationship of preoperative CEA levels with stage of disease, histology and resectability was also examined. All of the patients with CEA levels >6 ng/ml died in less than 3 years while all of the patients who survived 3 to 5 years had preoperative CEA levels ≤ 6 ng/ml. The CEA assay had no prognostic significance for patients with undifferentiated large or small cell carcinomas since all of the patients with undifferentiated large cell carcinoma had CEA levels ≤ 6.0 ng/ml and all of the patients with small cell carcinoma have died regardless of their initial preoperative plasma CEA value. The number of patients in these two histologic groups was small and perhaps the study of additional patients will show a critical CEA level for these patients as well. There was no correlation observed between CEA levels ≤ 6 ng/ml vs. >6 ng/ml and resectability of the primary tumor. The studies indicate, however, that preoperative CEA levels are of prognostic value in patients with epidermoid and adenocarcinoma who have values >6 ng/ml since all of these patients have died and all of the long term survivors had levels ≤ 6 ng/ml.

A review of 375 cases of aortic valve replacement with the Magovern-Cromie sutureless prosthesis demonstrated a 43 per cent survival rate 10 to 13 years following the operation. Of the 308 patients surviving zero to 30 days, 238 patients are alive after one to 14 years. A total of 70 patients (22 per cent died during the 14 year follow-up period. The actuarial survival rate of all patients at risk was 64 per cent at the fifth year and 51 per cent at the tenth year. For those patients who lived at least one year after surgery, the probability of survival was 84 per cent and 70 per cent at 5 and 10 years, respectively. These results compare favorably with reports of up to only 8 years with the Smeloff-Cutter and Starr-Edwards prostheses. There was only a 1.5 per cent incidence of perivalvular leak with this method of fixation, and no valve has migrated. Ball variance has not occurred with any valve inserted since 1964, and the incidence of thromboembolism with the Model A4 prosthesis is 2.4 per cent. Improvement in results depend on reduction of thromboembolism, lessening of late and operative morality rates, and by earlier operative intervention to reduce the late deaths from cardiogenic factors.

A small light-weight nuclear-powered pacer has been developed. The pulse generator weight 61 Gm. and occupies a volume of 33 sq. cm. It is a standard R-wave inhibited (VVI) demand pulse generator. The unit has met all United States and foreign atomic energy commission safety specifications including mechanical shock, industrial fire, accidental crush, cremation, impact, and corrosion. Its calculated life is in excess of 20 years. The unit has been shown to be insensitive to electromagnetic interference (EMI) over a wide range of commonly encountered sources of interference. An extensive dog testing program has been carried out and is continuing. The United States Atomic Energy Commission (AEC) has issued a license to conduct clinical trials. These began in October, 1974, and a total of 30 units of 30 units have been implanted so far. An equal number of chemical battery-powered pulse generators has been implanted in a control series of 30 patients. Preliminary results have been gratifying.

Familial myxomas of the heart are very rare, with only two previous reports noted in the literature. This report documents four siblings with myxomas, and three of these patients had two or more myxomas. One sibling had four myxomas excised. The clinical findings, history, examination, and surgical treatment are described.

1. Direct surgical denervation of the carotid sinus would appear to offer the best long-term results for carotid sinus syncope. 2. Carotid sinus denervation should be done under temporary cardiac pacing for safety and for completeness of denervation. 3. Arteriography is indicated to eliminate those cases of cerebral vascular insufficiency that might mimic carotid sinus syndrome. Credit must be given to Dr. R. Hughes, Clearfield, Pa., who recognized this diagnosis and referred the patient for therapy.

The clinical details of a 60-year-old woman with bronchoesophageal fistula is reported. This lesion probably persists into adulthood because initial pulmonary symptoms are mild and are not fully investigated. Cine esophagogram is recommended, on review of the literature, to be the most rewarding diagnostic procedure.