A technique for complete replacement of the aortic valve and ascending aorta in cases of aneurysm of the ascending aorta with aortic valve ectasia is described. The proximal aortic root was too attenuated to afford anchorage to the aortic prosthesis, so this was sutured to the ring of a Starr valve and the prostheses were inserted en bloc. The ostia of the coronary arteries were anastomosed to the side of the aortic prosthesis.Aneurysmal dilatation of the ascending aorta is often associated with ectasia of the aortic valve ring and presents clinically as aortic incompetence. In Marfan's syndrome or cystic medial necrosis this may develop with dramatic suddenness in an ostensibly healthy individual.The dilatation of the valve ring makes repair or replacement with other than a prosthetic valve difficult. The aneurysm, which is either a true dilatation or dissection, is best treated by excision and replacement with a tubular prosthesis, as the wall is invariably attenuated. This is not difficult provided that the aorta distal to the aneurysm and proximal to the arch is suitable for anastomosis.Proximally, in most cases, the aortic prosthesis can be sutured to a rim of aorta, leaving the coronary ostia undisturbed, while a valve prosthesis is placed in the usual sub-coronary position (Cooley, Bloodwell, Beall, Hallman, and De Bakey, 1966).However, it sometimes happens that the root of the aorta is so involved in the disease process that the wall is too attenuated to be sutured to the proximal end of the aortic prosthesis. In this situation the management of the coronaries is the main concern of the surgeon. Figure 1 gives an idea of the attenuation of the wall. Total cardiopulmonary bypass was established, and, after cross-clamping the aorta distal to the aneurysm, the aorta was opened, and the coronaries were cannulated and perfused in the usual way. The aortic valve ring was much dilated and the wall was extremely thinned down to the ring.It was clear that it would not be possible to join the aortic wall above the coronaries to an aortic prosthesis. It was therefore decided to suture the tube prosthesis directly to the ring of a Starr valve. A No. 13 Starr valve was sutured to one end of a crimped Teflon aortic prosthesis, as shown in Figure 2. The aortic cusps having been excised, sutures were placed in the aortic ring and through the Starr valve ring.These were tied, fixing the Starr valve and the attached Teflon tube.At this stage the coronary cannulae were outside the lumen of the aortic replacement. Holes were cut in the aortic prosthesis at the site of the coronary ostia, which were then re-cannulated, this time through the lumen of the tube (Fig. 3). The aortic wall was sutured to the perimeter of the holes in the Teflon tube, thus reincorporating the coronary ostia within the new aorta.The distal anastomosis was then completed, leaving a vertical slit (Fig. 3 (5)) through which the coronary cannulae were removed and air was evacuated. This was then closed with a clamp while the aortic clamp was released ...

It was shown by Stocks (1950) Legon (1951Legon ( , 1952 in attempts to correlate the geographical variations in the mortality from gastric cancer with variations in the organic content of the soil.It occurred to one of us that there might be a correlation between the high northern incidence of cancer of the stomach and the genetic differences which are reflected in the ABO blood groups, the frequency of blood group 0 being greater, that of A less, in northern than in southern populations, B and AB being similar in all geographical areas in England and Scotland.Previous published work on the association of the ABO blood groups with cancer has been on very small series of cases without adequate controls. The results have been diverse and without statistical significance (Alexander, 1921 ; Johannsen, 1925;Goldfeder and Fershing, 1937). MethodA collection was made of cases of cancer of the stomach from a number of hospitals in England and Scotland, and the distribution of the ABO blood groups in patients with stomach cancer from each hospital was compared with the distribution of ABO blood groups in an equal number of patients chosen at random from the same hospital. The criterion of diagnosis has in most cases been a histological

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This study concerns the longterm effects of both epicardial and endocardial cryosurgery with particular reference to the coronary arteries. Sheep were subjected to epicardial cryosurgery without cardiopulmonary bypass, and to endocardial application with bypass. In both groups the heart was kept beating throughout the operation. Neither cardioplegia nor aortic cross-clamping was used. In the first group applications were made for 5 min directly over or adjacent to a major branch of the left coronary artery. In the second, the cryoprobe was applied for 5 min or until atrioventricular dissociation occurred. No sheep developed late arrhythmias or evidence of myocardial ischaemia. Only minimal arterial changes were observed and all the major coronary arteries remained widely patent. Cryothermia to the heart produced a small discrete lesion without complication. Bright fluorescence of necrotic myocytes was observed in all the immature lesions when sections stained with haematoxylin and eosin were examined under ultraviolet light. This vivid fluorescence clearly delineated the extent of the lesions and persisted while cytoplasmic elements remained. Our results indicate that cryosurgery provides a safe and permanent technique for the surgical treatment of arrhythmias in man, and may safely be used even in proximity to the coronary arteries. Cardioplegia is contraindicated.

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