Certain observations are described in 81 neropsy patients (aged 29-91 years [mean 62]; 77 [95%] men) with severe congestive heart failure (CHF) of greater than 3 months duration, left ventricular (LV) transmural scar, and greater than 75% cross-sectional area (XSA) narrowing by atherosclerotic plaque of 1 or more of the 4 major epicardial coronary arteries. The duration of symptoms from initial onset of acute myocardial infarction (59 patients) or CHF (18 patients or angina pectoris (2 patients) to death ranged from 0.5 to 18 years (mean 7.1) (2 unknown). Angina pectoris occurred sometime, however, (59%); sudden (arrhythmia) in 16 (20%); acute myocardial infarction in 11 (14%), and emboli in 6 (7%). The heart weight ranged from 410 to 800 g (mean 585). Left and/or right ventricular thrombi occurred in 37 patients (46%), only 4 (10%) of whom had systemic emboli; of the 44 patients without intracardiac thrombi, none had emboli. The severity of coronary narrowing was variable. In 24 patients (30%) only 1 artery was narrowed greater than 75% in XSA; in 22 patients (27%), 2 arteries were so narrowed, in 32 patients (39%), 3 arteries, and in 3 patients (4%), 4 arteries were so narrowed. The size of the LV scar also varied. Of the 81 patients, 58 (72%) had large scars (involving greater than 40% of the LV wall); 10 (12%) had moderate sized scars (6-40% of the LV wall); and 13 (16%) had small scars (greater than 5% of the LV wall). The size of the LV scar correlated with a history of habitual alcoholism: of the 16 habitual alcholics, 7 (11%) had small and 50 (77%) had large LV scars (p less than 0.05). The chronic CHF in the 68 patients with either moderate or large-sized LV scars is readily attributed to the LV damage; in the 13 patients with small LV scars, however, the chronic CHF more reasonably may be attributed to another factor, e.g. alcoholism, despite coronary artery narrowing similar in severity to that in the patients with large LV scars.