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Changes in hemodynamics, inotropic state, and myocardial oxygen consumption were investigated in a total of 70 patients with coronary disease after intravenous application of nitroglycerin (0.4 mg., 0.2 mg., and 2 mg. per hour). The results demonstrate that nitroglycerin enlarges therapeutic possibilities during and immediately after operations in patients with limited coronary reserve. The decrease in myocardial oxygen consumption, dependent on dose, ranged between 15.8 and 22.9 per cent.

From 1974 to 1976 104 infants (under 1 year of age) underwent intracardiac correction for congenital heart diseases. Mean age and body weight were 6.6 +/- 3.6 months resp. 5.66 +/- 1.4 kgs. The diagnoses and mortality rates were: transposition of the great arteries (TGA) with intact ventricular septum 27 (0), TGA plus associated anomalies 9 (0), ventricular septal defect (VSD) 20 (1), VSD plus associated anomalies 6 (1), total anomalous pulmonary venous drainage 9 (5), pulmonary stenosis and pulmonary atresia with intact ventricular septum 9 (2), aortic stenosis 7 (3), ASD I or II 7 (0), and miscellaneous 10 (3). Intracardiac correction was performed either on cardiopulmonary bypass and moderate hypothermia or in deep hypothermia with or without total circulatory arrest. The early mortality in the first group was 7% (6 out of 90), in the second group 64% (9 out of 14). With increasing experience, cardiopulmonary bypass has proven to be a save method for intracardiac correction of congenital heart anomalies in infancy even in the youngest age group under three months of age and under emergency conditions.

After treatment of herniation of a lumbar disc by injection of the enzyme chymopapain, i. e. after chemonucleolysis, anaphylactic reactions can occur in about one per cent of the cases. In order to recognise the pattern of signs associated with such reactions, well in advance, while avoiding the additional risk of general anaesthesia, some authors propagate local anaesthesia. We report on our perioperative procedure in 102 cases of chemonucleolysis under local anaesthesia. Prick's tests were carried out before surgery to exclude sensitization to the substances to be injected. In two cases only due to a positive prick test to chymopapain chemonucleolysis had to be effected with collagenase; as a matter of fact, collagenase is not known to have caused any anaphylactic reactions, but it may be responsible for local side effects, such as destruction of adjacent tissues. The patients were kept under observation by an anaesthetist during and after surgery. No anaphylactic reaction was seen. Chemonucleolysis appears to be a suitable treatment method provided it is carried out under local anaesthesia with the same precautions as applied under regional anaesthesia by the anaesthetist.

Since the introduction of etomidate by JANSSEN et al. (1971) and the first clinical reports by DOENICKE et al. (1973 a-e, 1974) there has been much interest in this new imidazole-carboxylate hypnotic. All of the clinical investigations have been performed in volunteers or patients with a normal cardiovascular system (BRUCKNER et al., 1974; KETTLER et al., 1974). In these patients etomidate had only little influence on haemodynamic parameters.

In 6 children under 2 years of age correction of congenital heart defects required reconstruction of the right ventricular outflow tract including replacement of the pulmonary valve. Outflow tract reconstruction consisted in implantation of a size 14 valved conduit in 2 patients with d-TGA and subpulmonary stenosis and 1-TGA and subpulmonary stenosis, and a size 16 valved conduit in 2 other patients with truncus arteriosus. In 2 children with DOLV, VSD and aneurysm of the pulmonary artery trunk, the pulmonary valve was replaced by porcine heterografts, sizes 19 and 21 respectively, after primary patch reconstruction of the right ventricular outflow tract. There was one operative death in a child with d-TGA, intact ventricular septum and severe subpulmonary stenosis. This child died in low cardiac output, probably because too much contractile muscle was lost at the site of anastomosis with the conduit. For reconstruction of the right ventricular outflow tract, pulmonary valve replacement has proven mandatory in cases with pulmonary hypertension in order to prevent postoperative right heart failure. Similarly, in cases with pulmonary stenosis and hypoplastic pulmonary arteries, postoperative pulmonary insufficiency can be deleterious to the right ventricle.

During open heart surgery hemodynamic changes due to 1.5% enflurane, 0.75% halothane, 0.18% methoxyflurane and 3.4% fluroxene have been compared. The following parameters have been measured: arterial pressure, heart rate, cardiac output, right and left atrial pressure, left ventricular pressure and dp/dt. The strongest effects were found with enflurane and halothane. Marked reduction in cardiac index, stroke index, left ventricular dp/dt as well as reduction of peripheral resistance caused severe systemic hypotension. Because of its slow uptake methoxyflurane was followed by small hemodynamic changes in this study. The rapid acting fluroxene had caused only minor reductions of cardiac output, stroke volume and dp/dt. There was no decrease in peripheral resistance.