Studies on Glucose Metabolism

Group III.-Mitral stenosis, judged oper- able, trivial or no symptoms, and systemic embolism.With atrial fibrillation operation is advised.Sinus rhythm is uncommon ; if present we generally recommend operation.Group IV.-Systemic embolism has occurred, but closed valvotomy will not improve valve function.(a) Patients with heavily calcified disorganized valves which are probably more stenotic than incompetent.Operative embolism is a grave risk, occurring in 16% with atrial fibrillation.There is a 12% risk of post-operative emboli.An operative mortality of 13% is considerably higher than for non-calcified valves.(b) Dominant mitral incompetence.20 such patients had closed surgery, 6 died at opera- tion, and three had recurrent emboli despite atrial appendagectomy.Atrial appendagectomy alone does not pro- ,tect against future emboli, especially if valve function cannot be improved.With a heavily calcified valve, a high surgical mor- tality rate, risk of operative embolism, and limited benefit make it difficult to recommend closed surgery despite previous embolism.In this situation anticoagulant treatment might be considered.Pre-operative embolism in a random group of 104 patients in this series was no com- moner with a large than with a small appendage, as assessed radiologically.Conversely, in 105 patients with systemic embolism large appendages were as common as small appendages.Our findings differ from those of Dr. W. Somerville and Dr. Jane Chambers (p.1167), and in our opinion a large atrial appendage is not an additional reason for operation.-Weare, etc., N. COULSHED.