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The treatment of congenital heart disease may be palliative because many residua and sequelae persist into adulthood. Except for trivial lesions and anomalies such as PDA or secundum ASD where surgical cure is possible, continued supervision is mandatory. These patients deserve expert medical assessment from adult cardiologists and from other specialists when appropriate. The prevalence of postoperative adult congenital heart disease is increasing: by the year 2000 it is estimated that over 2000 in each million of the adult population will have congenital heart disease, one third of these having undergone cardiac surgery. It is important that some adult cardiologists in each major centre develop skills in adult congenital heart disease for this new patient population.

The treatment of congenital heart disease may be palliative because many residua and sequelae persist into adulthood. Except for trivial lesions and anomalies such as PDA or secundum ASD where surgical cure is possible, continued supervision is mandatory. These patients deserve expert medical assessment from adult cardiologists and from other specialists when appropriate. The prevalence of postoperative adult congenital heart disease is increasing: by the year 2000 it is estimated that over 2000 in each million of the adult population will have congenital heart disease, one third of these having undergone cardiac surgery. It is important that some adult cardiologists in each major centre develop skills in adult congenital heart disease for this new patient population.

Two patients with Down syndrome, intracardiac communications and elevated pulmonary arteriolar resistance presented early in life. Both patients had significant stenosis of pulmonary veins. The progressive nature of the stenosis is illustrated in one patient. Pulmonary venous stenosis in Down syndrome has been recorded only twice before in the literature, and may play a part in the early onset of pulmonary vascular occlusive disease in some patients.

Noninvasive Doppler cardiac output measurements are clinical standards in adults and children. Presently, these standard Doppler methods generally require relatively expensive and large imaging equipment with complex signal-processing techniques. Thus, universal access to these important measurements has been limited. Simple, portable Doppler methods have been validated previously and applied to infants and children without cardiac disease. Nevertheless, these specific, inexpensive techniques have not been validated in children with complex congenital heart disease. Accordingly, we compared a noninvasive, suprasternal, non-image-guided, pulsed Doppler cardiac output with standard invasive Fick cardiac outputs in 20 patients (age range, 1 month to 15 years) with congenital heart disease. Doppler cardiac output was displayed by multiplying the mean velocity with an operator-selected angiographic or echographic estimate of the aortic diameter. The values from linear regression analysis were r = 0.96; Doppler cardiac output = 0.98 x Fick cardiac output - 0.08 L/min (range, 0.55-3.10 L/min). The 95% confidence limits were less than 35% of the mean of Doppler and Fick cardiac outputs across the range of measurements. We conclude that relatively linear and accurate measurements of cardiac output can be made by this simple, inexpensive, portable method in selected infants and children with various forms of congenital heart disease.

The prevention of infective endocarditis is extremely important for people with valvular heart disease and other high-risk cardiac conditions. The following is the National Heart Foundation's updated recommendations for the prophylaxis of infective endocarditis. The recommended antibiotic regimens have changed considerably from the previous guidelines. In response to these guidelines, Pharmac has instituted a number of changes to the Schedule to reduce the barriers to prescribing the recommended drugs for this indication. Pharmac expects that the last of these drugs to be listed on the Schedule (cefuroxime axetil) will be in place by 1 October 1999. Prescriptions will need to be endorsed "prophylaxis for endocarditis". Therefore, any prescriber (doctor or dentist) will be able to prescribe the recommended drugs on an endorsed prescription but, until 1 October 1999, some of the drugs may not be fully subsidised. Pharmac will be informing prescribers of the details of these changes in the near future. The Ministry of Health has recently alerted practitioners to the possible risk of heart valve damage following the long-term use of weight-loss drugs fenfluramine (Ponderax) and dexfenfluramine (Adifax). All patients who have taken these drugs for longer than 3 months should have a clinical check and, if any abnormality is detected, should be referred to a cardiologist. If mild or greater aortic or mitral regurgitation is present, antibiotic prophylaxis against endocarditis is recommended.--Boyd A Swinburn, Medical Director, National Heart Foundation.

Modification of the double-button (Sideris) patent ductus arteriosus (PDA) occluder has resulted in a single-strut aortic component rather than the conventional cross-strut design. We report the use of this infant PDA occluder for transcatheter closure in three patients with PDA measuring 2 mm, 3.7 mm, and 4 mm. Subclinical aortic perforation with a small aortic aneurysm developed in two patients 1 year after occluder implantation. The third patient had developed a small aortic aneurysm without perforation at 3-month follow-up. All three patients had a residual shunt and underwent successful PDA surgical closure with aortic aneurysmal repair. Single-strut umbrella designs are not recommended for PDA transcatheter closure.

This study examines the late outcome in patients with simple transposition of the great arteries (TGA) after a Mustard operation.Continuing medical follow-up for patients after the Mustard procedure, now extending to three decades, is required. The quality of life of adult survivors has not been well documented.Survival and quality of life among 113 hospital survivors of the Mustard operation performed for simple TGA between 1964 and 1982 were assessed by medical review and a lifestyle questionnaire. The incidence of right ventricular failure and echocardiographic right ventricular dysfunction (RVD) were determined. A measure of lifestyle, the ability index, was determined.Actuarial survival was 90%, 80%, and 80% at 10, 20, and 28 years, respectively, with 76% of survivors being New York Heart Association class 1. Sudden death, with an incidence of 7% without identifiable risk factors, was the most common cause of late demise. RVD was identified in 18% of patients who had echocardiography, but there was right ventricular failure in only two patients. Seventy-five percent of current survivors lead a normal life, 20% have some symptoms or lifestyle modification, and 5% are unable to work.The survival of patients to 28 years with the Mustard repair has been good. Late sudden death is the most worrisome feature. There is a 97% freedom from right ventricular failure to date. The quality of life of late survivors is good, most achieving a normal level of education and employment.

We examined the outcome of patients at high absolute risk of coronary events who had been discharged from the Green Lane Hospital risk factor clinic before publication of the 1993 National Heart Foundation of New Zealand (NHF) guidelines for management of dyslipidaemia.Consecutive patients who had been discharged12 months previously were followed up by general practitioner and patient questionnaires. Patients were categorised according to risk of a coronary event over 10 years. Ideal lipid levels (cholesterol5.2 mmol/L, high-density lipoprotein (HDL) cholesterol1 mmol/L, total:HDL cholesterol ratio5) and 'acceptable' lipid levels (cholesterol6.5 mmol/L for high risk,7.5 for moderate risk,8 in men and8.5 in women at mild or low risk) were defined according to the NHF guidelines.Of the 270 patients, 55.6% were at very high risk, 25.5% at high risk, 10.4% at moderate risk, 3.8% at mild risk and 0.7% at low risk. Twenty-four percent of patients were managed on diet alone at clinic discharge and 18% at follow up of 32+/-12 months. Total cholesterol (6.39 mmol/L), HDL cholesterol (1.22 mmol/L) and the total:HDL cholesterol ratio (5.71) were unchanged from discharge. In the very high risk group ideal lipid levels were achieved in only 12% at discharge and 7% at follow up. The corresponding figures for achievement of acceptable lipids at discharge compared with follow up were 48% and 39% for the high risk group, 88% and 79% for the moderate risk group and 93% and 93% for the mild risk group. The corresponding figures for achievement of ideal lipids were 4% and 8% for the high risk group, 0% and 5% for the moderate risk group and 7% and 7% for the mild risk group.Lipid levels achieved during clinic visits were maintained long term, but there were no improvements following publication of the NHF guidelines. Continued efforts are needed to increase awareness and implementation of the guidelines, particularly in patients at high risk. Removal of the restrictions on prescription of lipid modifying agents by general practitioners and improved interchange between general practitioners and specialists should greatly improve these outcomes.

To determine whether a numerical ranking system can provide an equitable basis for prioritising patients awaiting coronary artery bypass grafting.A review of the current coronary surgery waiting list was undertaken using a newly developed scoring system. The factors included in the score were age, symptoms, results of exercise testing, coronary anatomy, employment status and perceived surgical risk. This score was compared with a Canadian consensus system. Rankings were then compared with the clinical priorities given by clinicians when the patients were placed on the waiting list.There was excellent correlation between the two priority ranking systems using only those items included in the Canadian system (r = 0.9179). However, correlation between the Canadian system and the full Green Lane Hospital (GLH) scoring system was weaker (r = 0.6869). The Canadian system assigned higher surgical priorities than Auckland clinicians. Comparison between the GLH system and clinical priority gradings (O, urgent out of hospital), (A) and (B) showed considerable scatter. Waiting times for these three categories considered acceptable by the Canadian consensus group were two to six weeks for priority (O), six weeks to three months for priority (A) and three to six months for priority (B). The mean times on the waiting list for the 260 patients still awaiting surgery at GLH were two months for (O), 11 months for (A) and 22 months for (B).The Canadian and expanded GLH ranking systems are no more than aids to establishing priorities. They cannot replace clinical judgement because the importance of individual scoring items is heavily influenced by the ranking of other items. Waiting times for surgery are now grossly excessive despite the use of criteria for entry to the waiting list which are very conservative by international standards. There is no equitable or clinically acceptable way to modify priorities to reduce waiting times, and institution of a booking system is impractical.

In a tertiary referral centre 63 patients underwent 67 treatment periods with enalapril. The median age was 5.4 months. All children had signs of heart failure: congestive cardiac failure with breathlessness at rest was present in 88%. Haemodynamic groups were left-to-right shunt (n = 15), impaired ventricular function (n = 14), after cardiac surgery (n = 23), valvar regurgitation (n = 12), and hypertension (n = 3). Serial clinical, radiological, and laboratory data were used to judge outcome. The mean (SD) maximal dose was 0.30 (0.21) mg/kg/day. Thirty nine (58%) patients improved, 20 (30%) showed no improvement, and eight (12%) had side effects requiring discontinuation of enalapril. Renal failure in eight patients was related to young age, low weight, and left-to-right shunt group. Three patients died in congestive heart failure with renal failure. Enalapril was clinically safe and effective for children with cardiac failure secondary to ventricular impairment, valvar regurgitation, or after cardiac surgery. Renal failure was a problem in young infants with left-to-right shunts.

To describe the initial New Zealand experience of transcatheter patent ductus arteriosus closure in adults and children.Twenty-three children beyond infancy and four adults with isolated patent ductus arteriosus were selected for transcatheter umbrella closure. Rashkind umbrellas were placed across the patent ductus arteriosus through a percutaneously inserted long venous sheath using the Mullins technique.In 25 of the 27 patients a Rashkind umbrella was placed accurately. In two patients the umbrella could not be placed accurately: in one the procedure was abandoned uneventfully and in one the umbrella embolised to the right pulmonary artery necessitating surgical removal of the device and patent ductus arteriosus closure. There were no other significant complications. A second umbrella insertion is planned in two children for a significant residual leak at 1-year follow up.Transcatheter patent ductus arteriosus closure is a low risk and usually effective alternative to surgical closure for the majority of patients beyond infancy.

Percutaneous balloon angioplasty was successful initial treatment for 2 infants who, early after operation, developed obstruction at the proximal anastomotic site of a modified Blalock-Taussig shunt. Two years later the first child had not required reoperation and the dilatation site was patent angiographically. The other baby progressed well after angioplasty but because of surgical concern about the long-term success of angioplasty, shunt surgery was repeated, the baby dying after reoperation. Angioplasty of proximal obstruction in these shunts is feasible and satisfactory long-term palliation can be achieved avoiding repeat shunt surgery before the more definitive Fontan-type procedure.

One hundred and one subjects were randomised to receive either aspirin 100 mg or aspirin 100 mg + dipyridamole 300 mg daily before undergoing coronary bypass surgery. The drugs were commenced at least 36 hours before operation and patients were followed for one year. There were three perioperative deaths and 37 withdrawals, of which 14 were drug related (aspirin four, aspirin + dipyridamole ten). Cineangiocardiograms at nine weeks and one year showed vein graft patency rates of 93% and 87% for subjects treated with aspirin alone; and 90% and 89% in those who received aspirin+dipyridamole. During the follow-up period 14% of 232 coronary lesions in the aspirin treated group advanced by more than two grades compared with 15% of 315 lesions in the aspirin+dipyridamole group. The study did not establish superiority of one regimen over another in terms of graft patency or progress of lesions in native vessels. However, low dose aspirin was better tolerated than combination therapy.

to assess the hypocholesterolaemic effect of adding 50 g of oatbran to the diet of hypercholesterolaemic subjects already prescribed a diet with less than 30% of energy from fat.twenty-nine volunteers aged 21-67 years with total serum cholesterol levels 5.59-8.5 mmol/L prescribed a diet containing less than 30% of energy intake as fat, and with a body mass index between 19.8 and 29.3, were enrolled in a crossover study to assess the effect of the addition to the diet of 50 g daily of oatbran. After six weeks of an oat-free control diet, subjects were randomised to eat 50 g daily of oatbran or to continue on the oat-free diet. Six weeks later the subjects crossed to the alternative diet for a further six week period. Lipid levels were assessed in weeks five and six of each study period.twenty-four subjects completed the study consuming 51.7 (SD 15.5) g of oatbran daily during the treatment phase. No significant difference was seen between the oatbran and control diet periods in body mass index, energy or fat intake, or in total cholesterol, LDL and HDL fractions, apolipoprotein A1 and B levels, or triglyceride levels. Considerable variation was observed between the paired lipid results.ingestion of 50 g of oatbran daily by hypercholesterolaemic subjects on a low fat diet showed no influence on serum lipid levels. The importance of using at least duplicate samples in assessing changes in lipid values is emphasised.

Records of 34 children diagnosed as having Kawasaki disease in the Auckland region from 1979 to 1988 inclusive were reviewed. Diagnostic and associated features were similar to those reported from North America and Japan. The incidence (average 5.1 per year per 100,000 less than 5 years of age) was similar to that reported in Europe and North America amongst nonorientals and was similar in Polynesians and nonPolynesians. Coronary artery abnormalities were found in five cases (15%), and two cases, both of whom presented before five months of age, died. Those with abnormal coronary arteries had fever for a significantly longer period than those with normal coronary arteries.

Two hundred and eighteen patients with congenital valvar aortic stenosis aged between 1 and 25 years at presentation were followed for one to 26 years (average 8.7 years). Assessment of severity of aortic stenosis was essentially based on clinical findings including symptoms, the character of the pulse, and the behaviour of the second heart sound, management being further influenced by the degree of left ventricular hypertrophy shown in the electrocardiogram. There was reasonable correlation between clinical and haemodynamic assessment and all patients with a gradient between left ventricle and aorta (LV-Ao) greater than 50 mmHg (6.7 kPa) were judged to have moderate or severe aortic stenosis on physical signs. Fifty-five per cent of those judged mild on presentation still had a mild lesion 18 years later; 42 per cent of those judged moderate on presentation still had a moderate lesion 15 years later. Forty-four patients had an operation and of the 30 patients who underwent aortic valvotomy, only 40 per cent still had a satisfactory result 13 years later. There were three preoperative and seven postoperative deaths but in only two patients was death directly related to severe aortic stenosis and both of these patients had been lost to follow-up. It is concluded that indications for operation are aortic stenosis which is moderate or severe on physical findings, together with restrictive symptoms or ST and T wave changes on the electrocardiogram. Using these criteria, the risk of sudden death is minimal and irreversible myocardial damage unlikely. We do not recommend either routine cardiac catheterisation or routine operation at any arbitrary LV-Ao gradient.

Between 1964 and 1971, 49 patients were discharged from hospital following atrial baffle repair for transposition of the great arteries. Electrocardiograms of 47 of these patients were available for review seven months to eight and a half years (average 31 months) after operation. Of the 46 patients in sinus rhythm prior to operation, 40 (87%) were in sinus rhythm with normal atrioventricular conduction when last seen. Four patients (8.7%) had benign supraventricular dysrhythmias: three were junctional, one was atrial. None was noted to experience rapid dysrhythmias. Two patients showed evidence of abnormal atrioventricular conduction. There were five late deaths but in only one of these patients was a dysrhythmia a possible factor. The effects of variations in caval cannulation, extent of excision of the atrial septum and placement of the baffle suture line on the rhythm present at last review were examined. To preserve sinus rhythm it appears necessary to avoid surgical trauma in the vicinity of both the sinus node and the A-V node. Preservation of the internodal tracts appears less important. It is uncertain whether the 'sinus' rhythm seen after operation originates in the sinoatrial node but the rhythm is functionally similar.

Twenty cases of culture negative infective endocarditis admitted to the Cardiology Department of Green Lane Hospital from 1959 to 1980 out of a total of 265 cases (7.5%), were analysed retrospectively. Cases were included only when adequate proof of endocarditis was available at surgery or postmortem. Indiscriminate use of antibiotics before taking blood cultures was the most common association with failure to obtain positive cultures, seen in 16 of the 20 patients described. Failure to obtain positive cultures in four cases was attributed to inadequate bacteriologic techniques before 1967. Where no antibiotics were given prior to collecting blood cultures and bacteriologic techniques were adequate, proven culture negative endocarditis was virtually unknown. When antibiotics have been given, repeated blood cultures are recommended following withdrawal of antibiotic for at least four days.

A new-generation porcine valve fixed in glutaraldehyde at zero pressure and mounted on an acetal copolymer flexible stent was inserted in 97 patients between August 1983 and October 1986. The mean age of the patients was 51 years (range 10 to 76) and eight were under the age of 20 years. There were 57 mitral, 33 aortic, and 10 tricuspid valve replacements. Concomitant coronary artery bypass grafting was performed in 9% of patients, 40% underwent multiple valve operations, and in 40% the procedure was a reoperation. Mean follow-up was 26 months (range 12 to 49) and was 99% complete. There were no examples of primary tissue failure, and only to reoperations have been undertaken for infective endocarditis alone. The early mortality rate was 8.2% and the late mortality rate, 12.1%. Four late deaths were valve related (two caused by infective endocarditis and two by embolism). The actuarial 3-year survival rate was 70%, freedom from infective endocarditis 879%, freedom from embolism 87%, freedom from reoperation 90%, and freedom from valve-related complications 77%. All but three surviving patients were in New York Heart Association class I or II. Doppler echocardiography, performed in 62 of 76 survivors, showed thin and mobile leaflets in all patients and trivial or mild regurgitation in four (6%). The mean gradient across the Medtronic Intact valves (Medtronic Blood Systems Inc., Minneapolis, Minn.) in the aortic position was 17 +/- 5.2 mm Hg, in the mitral position 3.8 +/- 1.33 mm Hg, and in the tricuspid position 4.1 +/- 1.14 mm Hg. We conclude that early results with the Intact valve are encouraging.

Twenty-three infants, aged 5 days to 10 months, underwent repair of total anomalous pulmonary venous connection (TAPVC). Coronary sinus drainage was unusually common, accounting for 39 percent of the total. There were three early and four late deaths. Although the hospital deaths were related to perioperative errors, two of the infants appeared to have small left ventricles. Two late deaths in infants with coronary sinus drainage were due to obstruction to pulmonary venous return some distance proximal to the surgical anastomosis. All 16 survivors were well at last review, one after revision of his repair. Fifteen have undergone late reassessment, and one of these, also with coronary sinus drainage, showed evidence of pulmonary venous obstruction. Although the early survival rate is satisfactory, the late mortality rate has been significant and the high incidence of pulmonary venous obstruction in infants with coronary sinus drainage is of particular concern.

After aorta-coronary bypass grafting, 164 consecutive patients were randomized to receive propranolol 5 mg every 6 hours orally (n = 82) or to serve as control subjects (n = 82). All patients were receiving beta blockers preoperatively. There were no significant differences between the two groups. The incidence of sustained supraventricular (nonsinus) tachyarrhythmias was 23% in the control group and 9.8% in the treated group (p = 0.02). The incidence of ventricular arrhythmias was 15% in the control group and 2.4% in the treated group (p = 0.005). The overall difference in clinically important arrhythmias was 38% in the control group and 12.2% in the treated group (p = 0.0002). We conclude that low-dose oral propranolol in patients who were receiving beta blockers preoperatively is effective in reducing the incidence of clinically important arrhythmias occurring after aorta-coronary bypass grafting.

On hundred fifty-four patients who underwent open mitral valvotomy in the years of 1968 to 1976 were reviewed 1 to 112 months (mean 48) postoperatively. There was one hospital death and there were 14 late deaths (nine cardiac), and 16 patients required reoperation during the follow-up period. Preoperative factors were examined to assess their association with an unsatisfactory postoperative course. End points included unsatisfactory symptomatic status, the need for reoperation, and postoperative death. Maori race and atrial fibrillation (AF) were associated with all three end points. Other preoperative factors associated with at least one unfavorable end point were female sex, unfavorable preoperative symptomatic status, the presence of mild associated mitral incompetence (MI), a previous operation, and the presence of calcification in the mitral valve. The degree of subvalvular fusion and the adequacy of valvotomy assessed at operation were also related to outcome. A binary regression program was developed to assist in the prediction of outcome from an assessment of preoperative factors. Preoperative embolism occurred in 31 patients and postoperative embolism in 13. Postoperative embolism occurred in 35% of patients with a preoperative embolic episode and AF. Open mitral valvotomy carries a low operative risk, but unfavorable preoperative factors militate against a satisfactory long-term result and protection from recurrent embolism is only partial.

Serum digoxin levels were measured in 53 neonates and infants receiving 18-22 microgram/kg/day (high dose) oral maintenance digoxin, and 44 neonates, infants and children receiving less than 18 microgram/kg/day (low dose) oral maintenance digoxin. In both groups, patients under four months of age had significantly higher serum digoxin levels than older patients, in the high dose group 2.6 ng/ml compared with 1.4 ng/ml and in the low dose group 2.2 ng/ml compared with 1.0 ng/ml. Correlation between digoxin dosage and serum level was weak and unaffected by blood urea level. Only two patients in the entire series showed toxic manifestations. Sixteen patients had serum digoxin levels measured before and after corrective cardiac surgery while receiving comparable dosages of digoxin. Despite lower serum digoxin levels postoperatively pulse rates fell significantly, illustrating the influence of changing haemodynamic status on the inter-relationships of digoxin dosage, serum levels and clinical response. Recommended dosage regimens are outlined.

A systematic investigation was undertaken to determine which factors affect the calibration of a Gilford monochromatic densitometer used for recording indicator-dilution curves with indocyanine green. Calibration was not influenced by variation of withdrawal speeds from 6.4 to 20.6 cm3/min but varied with differing sampling systems. Variation in haemoglobin from 10 to 17.5 g·dl−1 or in haematocrit from 30 to 60% did not affect calibration. Calibration lines showed both curvature and hysteresis. The optical properties of indocyanine green were not affected by storage of diluted dye in the dark for 24 hours but were altered by the presence of contrast media used in angiography. No systematic error resulted from the substitution of stored ACD blood for patient's blood in calibration although random error was increased. Recommendations based on these findings are made for a simple calibration technique which avoids systematic error.

Ventricular septal defect repair had been performed in 57 infants ages 21 days to 21 months and under 10 kg in weight using profound hypothermia-circulatory arrest technics. Severe congestive heart failure was the indication for operation in all but two infants under 6 months of age, and in those under 3 months there was usually an associated moderate or large sized atrial septal defect or patent ductus arteriosus or a coarctation. In infants over 6 months controlled heart failure was accompanied by failure to thrive and often recurrent respiratory infections. The main indication for surgery in three infants was repeated severe respiratory infections and in 7 infants, ages 10-15 months, an elevation of pulmonary vascular resistance of 6 units M2 or more. There were two hospital deaths among the 49 infants without coarctation (ages 6 and 20 months) and two among the 8 with coarctation. Postoperative respiratory and other complications were uncommon. On late review there was no significant residual VSD amongst the 11 recatheterized patients. Psychometric studies in 19 children who had reached the age of three to four years gave no evidence of cerebral damage due to the circulatory arrest period. In view of these results palliative pulmonary artery banding is no longer performed for VSD in infancy unless there is a Swiss cheese septum or an associated severe coarctation.

A detailed review was made of 180 patients with severe aortic regurgitation of rheumatic origin. Of these patients, 110 underwent aortic valve replacement. Thirty-nine clinical and haemodynamic factors were studied in an attempt to define those associated with (1) death before surgery, (2) a higher incidence of complications and hospital mortality after surgery, and (3) an unsatisfactory longer-term result of surgery. Only heart failure, radiographic heart size, left ventricular hypertrophy, and ventricular premature beats were associated with death before surgery. No factor predisposed to surgical complications and only preoperative factors associated with an unfavourable result after surgery were advanced heart failure, cardiomyopathy, extreme cardiomegaly, and ventricular premature beats. It is concluded that the indications for operation are: a cardiothoracic ratio of greater than 0-60, or a history of heart failure combined with electrocardiographic evidence of extreme left ventricular hypertrophy. Operation may be safely postponed if these indications are not met, though the presence of ventricular extrasystoles or evidence of independent myocardial disease are further factors which should influence the decision.

In double outlet left ventricle,both the pulmonary artery and the aortaarisefromthemorphologicleft ventricle. This paper presents the anatomic and cineangiocardiographic features of five patients who had this condition proved at surgery or autopsy. The condition of the first patient was incorrectly diagnosed as transposition of the great arteries with pulmonary stenosis and ventricular septal defect; the anatomic features were correctly interpreted at operation in 1966 and appropriate repair was made, but the patient died postoperatively. The condition of the other four patients was correctly diagnosed. The second patient had Ebstein's malformation of the tricuspid valve and hypoplastic right ventricle in addition to double outlet left ventricle; her condition was not considered operable. Two patients, one with visceroatrial situs solitus, concordant d-loop and dextrocardia, were surgically treated with good long-term results. The fifth patient died 2 years postoperatively and is the first patient reported to have double outlet left ventricle with visceroatrial situs inversus, a discordant d-loop and levocardia. The segmental approach to the classification and diagnosis of connection disorders is discussed and the radiologic criteria by which double outlet left ventricle may be diagnosed considered in detail. The importance of using the radiologic projection (usually left anterior oblique) that profiles the ventricular septum is emphasized because the diagnosis can be established only by delineating the relations of the origins of the great arteries to the ventricular septum. The surgical significance of other anatomic features, including the number, size and position of ventricular septal defects and conal malformations, is also discussed.

The late hemodynamic and radiologic findings were good or excellent in 96 percent of 23 infants in whom tetralogy of Fallot was repaired with the use of profound hypothermia. These results encourage continuation of the policy of early repair rather than palliation in tetralogy of Fallot. The preoperative cineangiocardiographic assessment of the type and severity of the pulmonary stenosis accurately predicted the findings at operation and the type of repair required. In infants between 1 and 21 months of age and 3 and 10 kilograms in weight, a main pulmonary artery (MPA) diameter of less than 7 mm. was the cineangiocardiographic measurement most accurately predicting the necessity for an outflow patch across the pulmonary ring. Postoperative studies showed significant increases in the MPA and pulmonary ring diameters. A Method of cineangiocardiographic assessment of pulmonary incompetence is presented. Severe mechanical pulmonary incompetence in some patients produced mild hemodynamic effects by radiologic criteria.

The number of deaths from coronary artery disease is declining in New Zealand as in some other Western countries. It has been estimated that in 1981 in the Auckland metropolitan area there were 126 fewer deaths than would have been expected from the data in 1974. The contribution made by cardiac surgery to this decline was assessed from the known numbers of patients who were operated on, from their survival rate, and from the predicted mortality of the surgical cohort had they not undergone operation. Such mortality was predicted from past studies of patients with similar symptoms, exercise data, studies of unstable angina, and the coronary artery surgical study registry. From this method it was estimated that coronary surgery accounted for 26% to 42% of the reduction in coronary deaths. Two previous studies estimated, from calculations based on the European study of patients with modest symptoms, that the contribution of cardiac surgery was much lower. Extrapolating data from one subset of patients to a second subset with quite different characteristics is a conceptual fallacy.