The myocardium from 44 patients undergoing open cardiac surgery was studied to determine if alterations demonstrable with the electron microscope could be related to prognosis. Planimetric methods were used to evaluate myofibrils, Golgi, mitochondria, myelin figures, other organelles, and intracellular space in order to achieve as objective a measurement as possible. Morphologic changes were graded and correlated with clinical findings and results after long-term follow-up. Factors evaluated in terms of survival included patient age, degree and extent of valvular disease, the presence of coronary artery disease, and degenerative changes of the myocardium as demonstrated ultrastructurally. Patients dying, of cardiac causes, within the first 5 years, had a higher ultrastructural grade than those surviving for more than 10 years. Statistical analysis, using stepwise regression methods, demonstrated a highly significant correlation (P less than 0.001) between cardiac ultrastructural integrity and prognosis. The addition of age to the prediction model was also significant (P less than 0.04), using the two variable models, EM grade and age were, similarly, highly significant (P less than 0.001).