The results of operative treatment in 83 patients with idiopathic hypertrophic subaortic stenosis (IHSS) are described. Most patients with the disease are asymptomatic, or derive satisfactory symptomatic improvement from nonoperative therapy: administration of propranolol, exerice limitation, control of arrhythmia, etc. Operation is required, however, in 10-15% of patients, those who remain severely symptomatic after nonoperative treatment or who become refractory to it. Operation relieves symptoms in IHSS by relieving obstruction to left ventricular outflow, and for a patient to be considered an operative candidate severe obstruction must be documented at left heart catheterization either under resting conditions or after provocative interventions. All 83 patients were severely incapacitated--58 in Class III and 24 in Class IV. Seventy had obstruction at rest (average gradient 96 mm Hg), and 13 had only provocable obstruction. At operation the hypertrophic interventricular septum was exposed via an aortotomy, and a vertical bar of muscle was resected between parallel myotomy incisions. There were six operative deaths (7%); no patient has died since 1970. Seven patients have died late after operation, five of them from causes unrelated to their heart disease or the operation. All surviving patients describe symptomatic improvement. Fifty-two patients with obstruction at rest preoperatively (average gradient 95 mm Hg) have been studied postoperatively: no resting gradient was evident in 47, while in the remaining five the gradient was less than 25 mm Hg. Recurrence of obstruction has never been observed at late catheterization (21 pts) or late echocardiographic examination (37 pts). Obstruction could not be provoked postoperatively in ten of the 11 patients who had large gradients only with the Valsalva maneuver or isoproterenol administration preoperatively. Obstructed and provocable obstructed patients had similar symptomatic improvement after operation. A variety of rhythm and conduction abnormalities were observed both pre and postoperatively, and these are described in detail. The results of operation in these 83 patients with IHSS demonstrate that gratifying symptomatic and hemodynamic improvement uniformly follows left ventriculomyotomy and myectomy. Relief of obstruction and amelioration of symptoms have proved to be long-lasting during postoperative observation periods extending to 14 years. Continued application of the operative procedure in properly selected patients appears to be indicated.

Conventional linear x-ray tomography is often used to search for pulmonary metastases but tends to underestimate extent of disease when compared with operative findings. In a prospective study, operative findings were correlated with computed axial tomography and conventional linear tomography performed on 25 patients with a history of extrathoracic malignancy and pulmonary nodules. Computed tomography detected 69 nodules of which 31 proved to be metastases. Conventional linear tomography detected 38 nodules of which 25 were metastases. Of the 54 resected nodules measuring >3 mm, computed tomography detected 42; whereas conventional tomography detected 32. Only six of the 31 additional nodules (20%) detected by computed tomography and not by conventional tomography proved to be metastases. These results suggest that computed tomography is more sensitive than conventional tomography in detecting small pulmonary nodules; however, there is diminished specificity in identifying metastatic nodules.Cancer 43:913-916, 1979.HE APPEARANCE OF A pulmonary nodule T may be the first evidence of metastatic tumor in patients with an extrathoracic malignancy. Pulmonary resection for metastatic disease has proved effective in obtaining 30-35% five-year survivals in patients with carcinomas and sarcomas.2"0 Even in sarcoma patients with multiple bilateral pulmonary metastases a 25-30% five-year survival rate can be achieved when complete resection is possible.' The use of conventional linear tomography in the evaluation of patients with a history of an extrathoracic malignancy and a pulmonary nodule on chest x-ray has been useful in detecting additional pulmonary nodules in 30-35% of case^.^**'^ We have shown that conventional tomography can be a sensitive screening study for detection of metastatic disease in the presence of a normalPresented at the 31st Annual Meeting of The Society of Surgical Oncology,

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Autogenous vein grafts used for canine femoral and aortocoronary arterial bypasses were evaluated from 2 to 365 days postoperatively. Femoral grafts showed focal endothelial disruption, mural fibrin deposition, and medial edema with inflammatory infiltrates during the first week; loss of medial smooth muscle cells and focal subendothelial lesions with intact endothelium by 2 weeks; and diffuse subendothelial lesions by 12 weeks, Coronary grafts studied at 6, 9, and 12 months had medial fibrosis and extensive intimal proliferation causing up to 90% luminal narrowing. Extension of the intimal process into the coronary artery distal to the bypass graft also compromised the arterial lumen. Coronary grafts obtained from humans dying 17 and 57 days after graft insertion revealed a similar subendothelial proliferation. Electron microscopy showed that the subendothelial lesions were composed of mature smooth muscle cells and collagen primarily oriented parallel to the axis of blood flow. Recurrent endothelial cell damage, followed by mural fibrin deposition and organization, appears to be the cause of the subendothelial proliferative lesions.