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Treatment of congenital adrenal hyperplasia (CAH) in childhood focuses on growth and development and adult final height (FH) is a measure of effective treatment. We hypothesized that shorter adults will have more severe underlying disease and worse health outcomes.This was a cross-sectional analysis of 199 adults with CAH. FH and quality of life were expressed as z-scores adjusted for midparental target height or UK population height.FH correlated inversely with age (men, r = -0.38; women, r = -0.26, P.01). Men and women had z-scores adjusted for midparental target height of -2 and -1, respectively, and both groups had UK population height z-scores of -1 below the UK population (P.01). In women, FH was shorter in non-salt-wasting than salt-wasting classic CAH (P.05) and in moderately affected genotype group B women than either more severely affected groups null and A (P.01) or the mildest group C (P.001). Short stature and a higher prevalence of hypertension were observed in classic CAH patients diagnosed late (after 1 y) compared with those diagnosed early and in women treated with glucocorticoid only compared with those treated with both glucocorticoids and mineralocorticoids (P.05). FH did not associate with insulin sensitivity, lipid profile, adiposity, or quality of life.Adult CAH patients remain short, although height prognosis has improved over time. The shortest adults are those diagnosed late with moderate severity CAH and are at increased risk of adult hypertension; we hypothesize that these patients are exposed in childhood to high androgens and/or excessive glucocorticoids with potential programming of hypertension. Another possibility is inadequate mineralocorticoid treatment early in life in the late-diagnosed patient group. Prospective studies are now required to examine these hypotheses.

Two patients underwent resection and replacement of the ascending aorta using a low-porosity Teflon graft anastomosed with silk suture. In both patients false aneurysms developed that required operation 13 and 23 years postoperatively. The clinical courses of these patients, along with data from the literature, suggest that the combination of a low-porosity Teflon graft and a silk suture anastomosis presents a major potential hazard for the development of anastomotic false aneurysm.

Ventricular function was evaluated in 18 patients prior to left ventriculography and selective coronary arteriography. Simultaneous left ventricular pressure (catheter-tip manometer) and dP/dt were recorded at resting heart rates and during tachycardia induced by right atrial pacing. Pressure-velocity curves were constructed from which V max and maximum measured contractile element velocity (max V CE ) were obtained. V max and max V CE initially increased with pacing-induced tachycardia in 17 of the 18 patients. Eight patients developed evidence of myocardial ischemia during atrial pacing. During the period of myocardial ischemia there was a decrease in V max and max V CE in all eight patients despite constant or increasing heart rate. In the 10 patients who did not develop evidence of myocardial ischemia with pacing-induced tachycardia, V max and max V CE continued to increase or remained constant with increasing rate. Peak left ventricular dP/dt increased coincident with the onset of myocardial ischemia in six of eight patients despite a fall in V max and max V CE in all eight patients during the ischemic period. A highly significant difference was demonstrated between V max values of patients with normal ejection fractions and patients with low ejection fractions, both at rest and during pacing-induced tachycardia.

Infarct site, extent, and the degree of associated asynergy are major determinants of the hemodynamic consequences of myocardial infarction. Although conventional electrocardiography and vectorcardiography are routinely employed in assessing the location and size of infarction, they are relatively nonspecific. The newer techniques of high-frequency electrocardiography and isopotential mapping offer promise but have yet to undergo systematic evaluation. A rough measure of the extent of infarction is obtained from serum enzyme measurements. However, they furnish no information with regard to localization. The region of infarction may be detected by precordial scanning following the intravenous or intracoronary injection of a radioisotope. The infarct may be revealed as an area of decreased perfusion (cold spot) or as an area to which a specific radioactive label is bound (hot spot). With the availability of newer radionuclides such as 43 potassium and the use of computer techniques, a more precise means of localizing and quantifying myocardial infarction may become available. Optimal definition of asynergy is obtained with contrast angiography. However, the risk of this procedure has limited its use, to date, in acute myocardial infarction. Apex- and kinetocardiography, chest X-ray, and fluoroscopy often suggest regional ventricular dysfunction, but these techniques are not sufficiently specific. Newer noninvasive methods for objectively evaluating regional ventricular dysfunction are ECG-gated cardiac scintiphotography and radarkymography. With ECG-gated scintiphotography, end-diastolic and end-systolic cardiac isotope images are obtained following intravenous injection of 99m technetium-albumin. From these images, assessment of asynergy and extent and location of infarct can be made. With radarkymography, heart-wall motion is assessed and quantitated by tracking segments of the cardiac silhouette visualized on a cinefluorogram. These techniques are ideally suited to the acutely ill patient. Echocardiography is another noninvasive technique with potential application to the study of asynergy. However, at present, only posterior-wall motion can be measured. At the time of surgery regions of infarction may be localized by means of chemical indicators (fluoroscein), isotope techniques, or epicardial electrocardiographic mapping. Recently much has been learned about the hemodynamics of myocardial infarction. Through the use of the techniques described, further insight into regional ventricular abnormality and extent and localization of myocardial infarction could be obtained. With this information better approaches to therapy and prognosis could be developed. Many students of the coronary circulation must have noted that the ventricular zone affected by ligating a large coronary branch not only appears cyanotic and dilated, but that it seems to alter in its mode of contraction. The detailed and sequential changes in contraction are not easily followed by the unaided eye and so far have not been recorded myographically. The reasons for this were the lack of an adequate and suitable myograph and a technique for the application of one to a limited ventricular surface so that records obtained represent, at least reasonably well, changes in muscle length and not predominantly artifacts due to position changes, thrusts and vibrations of the vigorously beating ventricle. 1

Indicators can be used to measure myocardial blood flow if the myocardial circulation can be isolated from other segments of the systemic circulation. Methods of measuring myocardial blood flow can be divided into groups according to the technic employed to provide "isolation" of the myocardium. There is no practical method of proved accuracy whereby coronary blood flow can be measured in man in absolute terms of ml./min. All the so-called clearance methods measure myocardial blood flow in flow/volume units or ml./min./100 Gm. Myocardial blood flow measurements in these flow/volume units have not proved useful in separation of normal individuals from those with ischemic heart disease at rest, but have been useful in the study of acute intervention such as exercise or the administration of drugs.

In 11 patients with hypertension associated with acute myocardial infarction intravenous phentolamine decreased the elevated left ventricular filling pressure. Cardiac index increased with a small decrease in arterial pressure, and therefore the same or increased stroke work was achieved at a lower filling pressure. In patients with acute hypertension myocardial oxygen demand was decreased and this may tend to increase infarct size. The potentially beneficial effects were less great in patients with chronic hypertension antedating the myocardial infarction.

Five cases of postoperative aneurysm of the ductus arteriosus are presented and discussed, together with 12 from the literature. The ductus had become recanalized in all 17 patients. Infection was present in 11, having existed preoperatively in only two of these cases. The evidence suggests that contamination at the time of surgery was responsible for the infection in at least seven cases.

Summary It is difficult to predict what the ultimate role of vein bypass surgery may be in the management of patients with ischemic heart disease. There is reason for optimism and it seems likely that this operation or its derivatives will find a permanent place in the therapeutic armamentarium. It is equally clear that there is need for a more precise definition of indications. The population to which the procedure should be offered may be much smaller or possibly much larger than that in which it is currently used. The best summary would appear to be the following listing of the facts that are known and not known at the time of this writing.

An early systolic click and a normal or accentuated aortic second sound have been found in cases of aortic valve stenosis characterized cineradiographically by a mobile, dome-shaped valve. Impaired valve mobility was usually associated with a systolic click of low intensity, and in the presence of an immobile aortic valve there was no systolic click. The aortic second sound was correspondingly diminished or absent. Early systolic clicks and loud aortic closure sounds were also present in patients in whom a diseased aortic valve had been replaced by three Teflon prosthetic leaflets. In most of these patients there was no systolic click before insertion of the prosthesis. In the patients studied, the systolic click occurred at the end of the opening movement of the aortic valve at the onset of left ventricular ejection. It followed the crossover point of the left ventricular and aortic pressure pulses by a time interval ranging from 15 to 45 msec. (average 33 msec.). The opening movement of the valve was thought to produce the systolic click by causing sudden tension of the valve membrane or sudden alteration in the velocity of blood flow. By analogy with the opening snap in mitral stenosis, the early systolic click may be regarded as the "opening snap" of the aortic valve. A systolic click is clinical evidence of a mobile aortic valve in patients with aortic valve disease.

1. 1. Fourteen patients with pulmonary hypertension received 20 mg. of sublingual isoproterenol, and the hemodynamic effects were measured. 2. 2. Isoproterenol increased pulmonary blood flow and decreased pulmonary vascular resistance, whereas pulmonary arterial and pulmonary arterial wedge pressures remained unchanged. 3. 3. Isoproterenol caused active vasodilatation of the hypertensive pulmonary vascular bed.

Summary Angiocardiography has been demonstrated to be a useful supplement to left heart catheterization in the study of mitral valve disease. Angiocardiography appears to be a sensitive method of detecting mitral regurgitation. The characteristic cineangiocardiographic features of mitral regurgitation have been described.

Seventeen patients with late hemodynamic complications of anastomotic surgery for the tetralogy of Fallot have been studied. Two syndromes have been noted and both seem related to shunts of greater than ideal size. The clinical characteristics of these syndromes are delineated.

Ten hospitalized patients performed two exercise tests per day on five consecutive days to determine the efficacy and duration of action of three sublingual long-acting nitrate preparations: isosorbide dinitrate, pentaerythritol trinitrate, and erythrityl tetranitrate. The duration of exercise to the point of ischemia, manifest as typical anginal pain and/or 1.0 mm ST-segment depression, was determined 45 min and 100 min after each long-acting nitrate was administered. These results were compared with the duration of exercise after placebo and two minutes after nitroglycerin administration. The mean durations of exercise in two tests after placebo were 62.5 sec and 58.4 sec (not significant) and the mean durations of exercise after nitroglycerin administration were 90.5 sec and 88.4 sec, both different from placebo ( P < .001). There was no difference from placebo found 55 min after taking nitroglycerin. The mean durations of exercise 45 min after erythrityl tetranitrate, isosorbide dinitrate and pentaerythritol trinitrate were 89.1, 87.5, and 87.5 sec respectively and all were different from placebo ( P < .01). Mean durations of exercise 100 min after erythrityl tetranitrate, isosorbide dinitrate, and pentaerythritol trinitrate were 76.4, 75.5, and 69.7 sec and none were significantly different from placebo. This study indicates that each long-acting nitrate is effective for at least 45 min and suggests that they should not be given on a fixed dosage schedule but rather should be taken prophylactically whenever an angina-provoking situation is anticipated.

A system of multiple-lead exercise electrocardiography has been applied to the study of 107 normal subjects and 67 patients with angina pectoris. The results of this test are compared to those of coronary cinearteriography in 84 patients. In-exercise ECGs gave useful additional information in 59% of the angina patients but were essential for interpretation in 9%. It added considerably to the safety of the test. The value of each individual lead and of the multiple lead system was assessed. Lead V 6 was the most often positive, but each made a contribution in some cases. Test-retest reproducibility survey indicated that five of 65 tests on 25 subjects failed to conform. Evidence has been presented that 1.0 mm of ischemic S-T segment shift was the best criterion for a positive test in the subjects studied. The test was positive in 84% of 67 patients with angina pectoris and 3.7% of 107 normal subjects (excluding vasoregulatory hyperreactors). The double two-step test given to the first 41 of the same angina patients for comparison was found to give 61% positive reactions despite the use of multiple leads and in-exercise recording. The test was administered to 84 subjects who were studied concurrently by selective coronary cinearteriograms and these two parameters were compared with the clinical diagnosis of angina in each patient. Since each of these parameters represents a different facet of coronary arterial disease, the agreement among them is very instructive.

The severity of the atherosclerotic disease of the coronary arteries is demonstrated to be an important predictor of survival in a group of 224 patients followed from 5 to 12 years after coronary arteriography. The group consisted of young patients (average age 41.8 years) without hypertension or congestive heart failure, who were studied during the stable phase of their disease. The current status of 218 or 97% of this group of patients is known.

While acute regurgitation is the most common valvular lesion associated with aortic sinus of Valsalva aneurysms, this report describes the pathological findings in five patients in whom primary right-sided valve dysfunction was simulated by sinus of Valsalva aneurysms. In two patients aneurysms of the noncoronary sinus projected into the right atrium at the level of the tricuspid valve and caused tricuspid incomptence. In three patients aneurysms of the right sinus of Valsalva projected into the right ventricle immediately below the pulmonic valve and caused pulmonary outflow tract obstruction. In only one of these patients was the aneurysm perforated at necropsy. Although valvular dysfunction was evident clinically, in none was there a clinical suspicion of a sinus of Valsalva aneurysm. In addition to valvular dysfunction, two patients had conduction disturbances and two, right coronary arterial occlusions found to be the result of aneurysms. The risks of valve dysfunction, arrythmias, aneurysm rupture, and sudden death and the ability to correct this lesion surgically make it especially important to consider aortic sinus of Valsalva aneurysm as a cause of obscure right-sided valvular disease.

A peculiar non-hypertrophic myocardiopathy is described which occurred in three and possibly five generations of a single family. Clinical features included systolic murmurs, electrocardiographic abnormalities, and sudden cardiac death with a paucity of symptoms of cardiac dysfunction. Pathological studies in three generations showed a striking similarity of cardiac findings including globular and dilated ventricles, endocardial fibroelastosis, and mitral valve thickening. Myocardium in two showed basophilic degeneration and fibrosis. A retrospective genealogic analysis and a prospective clinical evaluation of living family members suggested an autosomal dominant mode of inheritance with variable penetrance. The cause of this heritable myocardiopathy is presumably a mutant gene; the biochemical defect to which the mutant gene gives rise remains unknown.

The first 153 cases of saphenous vein aortocoronary bypass surgery performed at The Johns Hopkins Hospital were reviewed. Eighty-eight percent of the 140 late survivors reported significant symptomatic improvement. Seventy-one unselected patients consented to complete reevaluation at a mean interval of 6.1 months postoperatively. Vein bypass patency in this group was 66 percent. Eighty-two percent of these 71 patients had improved performance on electrocardiographic stress testing. There were no significant differences between hemodynamic status on pre- and postoperative studies regardless of the status of vein bypass patency. Repeat coronary angiography revealed a 30 percent incidence of new total occlusions of the intrinsic coronary circulation. Segmental wall motion on ventriculography was improved in 12 percent, unchanged in 50 percent and decreased in 38 percent of the segments analyzed. Localized electrocardiographic changes compatible with myocardial damage developed in the immediate postoperative period in 45 of these patients (63 percent); in 38 of the 45, these changes corresponded to new angiographic abnormalities. Physiologic mechanisms underlying symptomatic improvement were sought by identification of an “angina-producing” myocardial segment. In most instances, alleviation of angina could be related to either: (1) a patent bypass graft into an unchanged intrinsic coronary artery with presumed increased blood flow to the distal coronary segment, or (2) occlusion of the bypass graft and the corresponding coronary artery with probable infarction of previously ischemic myocardium. Current criteria for the selection of patients undergoing coronary bypass surgery are reviewed in the light of these findings. It is concluded that relief of disabling angina is the major indication for surgery. Prevention of myocardial infarction and improvement in left ventricular function are at present less reliable objectives.

Eighteen healthy human subjects participated in weekly sessions of five 10-minute trials of walking on a treadmill at 2.5 mph and 6% grade. Eight experimental subjects received beat-to-beat heart rate biofeedback during the exercise and were instructed to try to lower their heart rates; ten control subjects did not receive feedback. By the end of 5 weeks (25 trials), the experimental group showed a significantly lower mean heart rate (96.8 vs. 108.6 bpm), systolic blood pressure (114.0 vs. 131.3 mmHg), and rate--pressure product (11.0 X 10(3) vs. 14.3 X 10(3) bpm-mmHg) during exercise than the control group. These differences were maintained after crossover of the feedback provision for five more weeks.

The studies on natural history of ischemic heart disease are reviewed and the major predictors of mortality identified. The severity of the coronary atherosclerosis and the status of ventricular function are found to be more important predictors of survival than the clinical presentation. The objectives of therapy in patients with ischemic heart disease are (1) to improve the quality of life by reducing symptoms, (2) to improve ventricular function, and (3) to increase survival time. The results of surgical therapy are examined in relation to these three objectives. Symptomatic improvement is present in 85 to 95 percent of patients after surgery, but convincing evidence for improved ventricular function is lacking and controlled studies of natural history have failed to show that surgery increases survival time. Analysis of the mechanism of symptomatic improvement after surgery suggests that increased blood flow to the ischemic area as well as infarction of ischemic myocardium and the nonspecific effects of surgery may account for the improvement. The prevention of coronary atherosclerosis is viewed as an attainable long-term solution to the problem of ischemic heart disease.

IN THE case of absent or diminished pulses in the arms and neck the clinician is presented with a most dramatic physical finding. Although the observation itself is elemental, the interpretation may be difficult. Anisosphygmia, "pulsus incongruens," and "pulsus differens"1are terms which have been applied to pulse abnormalities of this general type. "Pulseless disease" is another name applied to some of these abnormalities.2Fortunately no eponyms have come into particular usage in connection with these cases, although the type of disease due apparently to arteritis is called Takayasu's disease in Japan.2b It is our purpose to present cases in which the seat of the disorder is near the origin of the great vessels from the arch of the aorta. Included are various combinations of stenosis and obliteration of various branches of the aortic arch resulting from various causes. This general clinical picture may be referred to

Occlusive changes in the intrinsic coronary arterial circulation were found in 50 of 71 patients 6.1 ± 0.8(± S.E.M.) after saphenous-vein bypass surgery. A new total arterial occlusion was found in 57 (30 per cent) of 188 major coronary arteries. These occlusions occurred in 29 per cent (20 of 68) of intrinsic coronary arteries with a patent graft, in 62 per cent (24 of 39) of those with an occluded graft, and in 16 per cent (13 of 81) of arteries not bypassed. A comparable reduction in segmental left ventricular motion was noted. Eighty-six per cent of the 71 patients had symptomatic improvement of angina; 60 per cent were asymptomatic. Thus, change in the intrinsic coronary circulation after bypass procedures is not inconsistent with relief of angina and must be considered in the evaluation of this operation.

Fifty-seven consecutive patients presenting with unstable angina pectoris or so-called pre-infarction angina were prospectively evaluated by clinical and angiographic studies. One patient died during angiography and another died of acute myocardial infarction 11/2 hours after cardiac catheterization. Forty-five patients had significant obstruction in two or three coronary arteries. The average left ventricular ejection fraction was 59 percent. Of 15 patients treated medically, 10 were potential candidates for surgery. One of these 10 died during hospitalization and 9 survived. The nine survivors were followed up for an average of 10 months; six reported symptomatic improvement, and one had an uncomplicated myocardial infarction 6 months after study. Aortocoronary saphenous vein bypass was performed in 40 patients, of whom 9 died during hospitalization and 31 survived operation. Of the 31 survivors, 1 had an uncomplicated myocardial infarction 9 months postoperatively; there were no late deaths in this group during a follow-up period averaging 16.7 months. Thirty of the 31 survivors reported marked symptomatic improvement, and 21 of these survivors were pain-free.

Two cases of constrictive pericarditis with intrapericardial cyst formation are presented. In each, a tricuspid diastolic murmur was present, and confirmation of a tricuspid valve gradient was obtained at cardiac catheterization. Angiographic studies revealed that the tricuspid valves were distorted by the cysts. In both patients, surgical excision was successfully achieved. In case 1 a blood-containing cyst was found, the etiology of which is obscure. Case 2 was associated with rheumatoid arthritis, and the compression resulted from a chronic abscess that probably arose at a previous pericardiectomy.

Current methods of measuring myocardial blood flow using 133 xenon have failed to separate normals from patients with ischemic heart disease at rest. In the present study such a separation was attempted by utilizing pacing-induced tachycardia (PIT) to stress the myocardium. 133 Xenon was injected into the left coronary artery to measure blood flow in 27 patients at rest and during pacing-induced tachycardia. Oxygen content was simultaneously measured in the aorta and coronary sinus of 13 of these patients. Pacing rates of 150 beats/min or greater were obtained in 21 patients. In 10 patients (group I), who developed ischemia, manifested either by typical angina or ischemic electrocardiographic changes during PIT, myocardial blood flow increased 32 ml/min/100 g of tissue ( P < 0.001). In 17 patients (group II), who did not develop ischemia, myocardial blood flow increased 12 ml/min/100 g of tissue ( P < 0.02). The increase in group I patients was significantly greater than in group II ( P < 0.02). Myocardial oxygen consumption increased 4.63 ml/min/100 g of tissue ( P < 0.01) in ischemic responders (group I) and 2.62 ml/min/100 g of tissue in nonischemic responders (group II). It is concluded that patients with an ischemic response to pacing-induced tachycardia had a greater increase in myocardial blood flow and myocardial oxygen consumption than patients who did not develop an ischemic response. This unexpected finding is best explained by an increased myocardial blood flow in the nonischemic areas of the myocardium which may result from a vasodilator response to ischemia.

The diagnostic significance of an elevation of serum alkaline phosphatase in the presence of a normal serum bilirubin is discussed. Attention is called to a group of patients with chronic infiltrative disease of the liver due to sarcoid, tuberculosis, Hodgkin's disease and other similar conditions in which this combination exists. Although less frequent than biliary obstruction, Paget's disease and metastatic carcinoma, these cases may present as diagnostic problems and knowledge of this chemical pattern may be helpful. Obstruction of the biliary duct should always be considered first when the serum alkaline phosphatase is found to be elevated as the therapeutic possibilities are brighter than in the case of any of the diseases under consideration herein.

A standardized FM magnetic tape containing various arrhythmias and artifacts was prepared for the purpose of evaluating QRS-wave detectors. The technical aspects of the preparation of the tape and the testing format are described. Two QRS-wave detectors were tested. Premature ventricular contractions (PVC's) caused the most difficulty, 97 per cent being detected by one type and 86 per cent by the second. T waves following PVC's were detected as QRS complexes 6 per cent and 1 per cent, respectively. Base-line shift and 60 Hz artifact produced 4.7 per cent and 1.7 per cent false positive detections. The over-all results suggest that these QRS-wave detectors are capable of performing satisfactorily in the usual monitoring setting.

The distribution and transcapillary exchange of albumin have been studied in patients with congestive heart failure and the results compared with a group of control subjects who did not have heart failure. The normal relation between vascular albumin mass and plasma volume on the one hand and transcapillary albumin exchange on the other does not exist in patients with congestive failure. The transcapillary albumin exchange rate, which presumably reflects capillary permeability, is decreased relative to the plasma volume and vascular albumin mass. It appears that decreased permeability of capillaries to albumin is associated with congestive failure and may be responsible for the increased plasma volume characteristic of this disease. The appearance of labeled protein in edema fluid has been studied in 7 patients and compared with the simultaneously determined serum disappearance curves. The albumin contained in the edema fluid constitutes a small fraction of the total extravascular albumin pool. The vascular albumin mass equilibrates less rapidly with the local edema albumin mass than with the total extravasenlar albumin mass.

Transseptal left heart catheterization has been carried out in 20 patients ranging in age from 18 months to 16 years. The left atrium was entered in 85 per cent and the left ventricle in 70 per cent of these patients. No complications occurred, and adequate hemodynamic measurements were obtained in the basal state. This technique appears to be superior to that of left ventricular apical puncture.

Permanent pacemakers are useful in the management of certain patients with arrhythmias in the absence of heart block. Five patients are presented, four of whom obtained a satisfactory response to pacing. Continuous electrocardiographic monitoring by means of a magnetic tape system is useful in diagnosis as well as in the evaluation of the effects of therapy.

1. 1. An air-supported ballistocardiograph was used to obtain simultaneous recordings of body acceleration and left ventricular pressure in 7 patients. 2. 2. An average correlation of 0.810 was found for the IJ amplitude of the ballistocardiogram and the maximal derivative of the left ventricular pressure. 3. 3. The ballistocardiographic wave measurements displayed a high sensitivity to alterations in the left ventricular maximal pressure derivative of successive heartbeats. 4. 4. These observations suggest the potential application of the ballistocardiogram as a noninvasive method for quantitatively monitoring the mechanical activity of the heart.

Summary and Conclusions Significant outflow tract obstruction was notseen byleft ventricular cineangiocardiography in seven patients with "hypertrophic subaorticstenosis."Catheter withdrawals through the leftventricle, recorded cinefluorographically, lo-calized the high pressure areas to portions ofthe left ventricle which emptied completely in early systole. Sustained systolic contractionin empty portions of the left ventricle pro-vides an explanation for the pressure gradi-entsinthesepatients.Isoproterenol infusions increased the rate and degree of left ventricular emptying, ob-literating portions of the cavity earlier andincreasingthepressure gradient.Themechanismof gradient production with- out obstruction was similar to the phenome-non observed in dogs receiving isoproterenol infusions. The cardiac muscle in these patients is ab-normally thick and the left ventricle emptiesmorerapidly than normal; therefore a "hyper- trophic hyperkinetic cardiomyopathy" is present.The nonobstructive

A mean transcapillary exchange rate for albumin and gamma globulin has been obtained from plasma disappearance curves of I 131 -labeled albumin and I 125 -labeled gamma globulin. A much closer correlation exists between transcapillary exchange rate for albumin and the plasma volume than between the rate and serum albumin concentrations. Also, for albumin this rate varies with plasma volume and circulating protein in such a manner as to suggest that the capillary permeability changes with changing plasma volume. The relation between vascular and extravascular albumin is consistent with this interpretation, the extravascular mass of albumin appearing to approach zero as vascular albumin approaches the vicinity of 0.35 Gm/Kg. In experiments in which I 131 -labeled albumin and I 125 -labeled globulin were employed to obtain simultaneous data on albumin and gamma globulin, a good correlation has been obtained between the simultaneously measured albumin and globulin transcapillary exchange rates. The ratio of the fractional capillary exchange rates of these 2 substances is very nearly the same as the ratio of their diffusion coefficients, a relation to be expected if diffusion is the mechanism of transcapillary exchange.

Left bundle-branch block (LBBB) was found to be associated with an unusually short left main coronary artery in 11 of 12 patients studied by selective coronary arteriography. The average length of the left coronary artery in this group of 12 patients with LBBB was 4.5 ± 1.7 mm as compared to 12.8 ± 0.8 mm in a control group. Four of the 12 had evidence of ischemic heart disease, one had mild aortic regurgitation, one had myocardiopathy, and one had a patent ductus arteriosus. No etiology was discovered for the LBBB in the remaining five patients. Mechanical and hemodynamic explanations for this association of a particular pattern of coronary anatomy with LBBB are proposed.

The aortocoronary-vein bypass procedure for the treatment of ischemic heart disease has been enthusiastically received because it represents a simple, direct, mechanical approach to the problem of coronary-artery obstruction. A section of saphenous vein is used to form a large-bore conduit between the aorta and a coronary artery distal to an obstructing lesion. An end-to-side anastomosis connects the vein to the coronary artery, and therefore the normal flow through the natural coronary circulation is not compromised, and collateral vessels around the site of obstruction are not likely to be damaged. The vein is connected to a new opening in the . . .

The clinical situation in which fever and valvular heart disease coexist presents a problem in differential diagnosis and management which is quite different from that associated with either condition alone. The causes of fever more or less peculiar to valvular heart disease are active rheumatic fever, bacterial endocarditis, drug fever, embolism, congestive heart failure, hemoglobin pneumonia, systemic lupus erythematosus, and atrial myxoma or thrombus. Bacterial endocarditis should be given first consideration when fever and heart murmur coexist.

THE DEVELOPMENT of coronary arteriography during the past decade has greatly expanded the ability to establish an accurate diagnosis of coronary arterial obstruction. Radiographic visualization of the coronary arteries provides an objective method for establishing the site and magnitude of vascular occlusion, and with increased experience the procedure has become both reliable and safe. 1-3 As a result of the information gained by this technique, a number of patients have now been operated upon successfully for the direct relief of a variety of coronary arterial lesions. Coronary atherosclerosis most frequently attacks the proximal portions of the coronary vessels, a fact which has been repeatedly documented by a number of pathological studies. In most instances the lesions involve the first several centimeters of the coronary arteries. However, in the recent past it has been noted that coronary atherosclerosis may be sharply localized to the first several millimeters of a coronary artery