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Closed surgical mitral valvotomy is the procedure of choice in most patients with symptomatic pliable mitral stenosis in developing countries. The procedure is efficacious and safe. Mitral valvotomy performed with a balloon has shown similar good results, with infrequent complications in selected subjects. Because there is a paucity of studies comparing the two techniques, this study was undertaken to compare the results of percutaneous balloon mitral valvuloplasty with those of closed commissurotomy as determined by catheterization studies. Forty-five patients with tight pliable mitral stenosis were randomly assigned to one of two groups: 23 patients had balloon valvuloplasty by the single catheter technique (group I) and 22 underwent closed surgical valvotomy (group II). The two groups were similar with regard to clinical and hemodynamic findings before intervention. Mitral valve area increased from 0.8 +/- 0.3 to 2.1 +/- 0.7 cm2 in group I (p less than 0.001) and from 0.7 +/- 0.2 to 1.3 +/- 0.3 cm2 in group II (p less than 0.001). Pulmonary artery pressure and pulmonary vascular resistance decreased in both groups, but these changes did not reach statistical significance in group II. Treadmill exercise time increased from 3.8 +/- 2.3 to 7.3 +/- 2.6 min in group I (p less than 0.001) and from 4 +/- 2.6 to 5.6 +/- 2.6 min in group II (p less than 0.001). There were no deaths. One patient in each group developed moderate (3+) mitral regurgitation. A small interatrial shunt (less than 1.5:1) was detected in three patients in group I immediately after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Only 1 case of lymphomatoid granulomatosis has previously been reported from South Africa. Experience with 4 such adult patients (2 blacks and 2 whites) is described. These patients were followed up for 15-48 months and none developed evidence of a lymphoma during this period. Fever, weight loss, cough and breathlessness were prominent symptoms in all patients. One patient, a black woman, with a diffuse interstitial pattern of lung involvement, had digital clubbing--a rare accompaniment that resolved after therapy. Dilated congestive cardiomyopathy was found in association with pulmonary nodules in a black male patient. All 4 patients were treated with cytotoxic regimens. The 2 patients treated with oral cyclophosphamide and prednisolone responded favourably. The possible explanation for paucity of reports of lymphomatoid granulomatosis from South Africa could be under-reporting, underdiagnosis or a true geographic/ethnic variation in the incidence of this condition.

The occurrence of a bleeding placenta praevia in a young woman, with a viable fetus and an acutely obstructed Lillehei-Kaster valve, provided serious difficulties in priorities and decision making. This has prompted an analysis of the problems which others may encounter.

One hundred and eighty-one patients with carcinoma of the upper thoracic oesophagus were intubated perorally using a Procter-Livingstone tube. The mortality was 16-6 per cent but, in the patients who survived, the palliation achieved, as judged by improved swallowing, was considered satisfactory. Factors influencing the success of intubation are also considered.

The life of a young woman was threatened by a large, recurrent, invasive desmoid tumour which penetrated the sternum. The combined thoracic and plastic surgical management is described.

This paper reviews our experience with the Lillehei-Kaster pivoting disc prosthesis in 155 patients with aortic and mitral valve disease. We employed 189 valves during the period 1971 to 1974. The early surgical mortality rates for isolated mitral, isolated aortic, and combined mitral and aortic valve replacements were 9 per cent, 14 per cent, and 3 per cent, respectively. Postoperatively, there was no evidence of significant hemolysis, and the gradients across the prostheses were satisfactory. Clinical evaluation of prosthetic function was made difficult by the infrequency of an opening click and the common occurrence of mid-diastolic murmurs even with minimal gradients. The most disturbing complication, which has led to our abandoning use of this valve, was thrombosis, which occurred in at least 10 per cent of the mitral and 5 per cent of the aortic valves. The cause is thought to be late prosthetic disproportion as the heart shrinks in size.

Malignant esophago-respiratory fistula is an incurable condition calsing severe distress to those patients suffering from it. Sixty two successive patients with esophago-respiratory fistulae, secondary to squamous cell carcinomas of the esophagus, were intubated for palliation. The first 14 were intubated by a traction technique using the Celestin tube, and the remaining 48 were intubated by the Procter-Livingstone tube inserted by a pulsion method. Celestin intubation had a mortality of 64.3% but 75% of those intubated by the Procter-Livingstone tube were discharged from hospital, swallowing satisfactorily and relieved of their respiratory distress. In our experience the insertion of the Proctor-Livingstone tube by a pulsion technique, can be performed in a few minutes, with little morbidity and allows the patient to be discharged from hospital within 3-4 days of the procedure. It is a successful and acceptable method of treating malignant esophago-respiratory fistulae.

Isolated mitral valve surgery was carried out in 182 children under the age of 16 years. Closed valvulotomy was performed in 72, annuloplasty or reconstruction in 10 and valve replacement in 100 of the children. Preoperative atrial fibrillation implied severe disease. Acute rheumatic carditis was not a contraindication to operation. Two patients died after closed mitral commissurotomy and the results were unsatisfactory in nine children with valve calcification and in 12 with a small jet of incompetence. Restenosis occurred in 10 patients during a review period of five years. The long-term results of annuloplasty were disappointing, and this procedure is not recommended for children with mitral incompetence. Ten of the 100 patients who underwent mitral valve replacement died in hospital and there were two late deaths. Seventy-seven patients are completely well and 11 have grade II disability. Severe mitral valve disease in children is associated with high morbidity and mortality, unless normal hemodynamics are restored. Since the results of operation are so satisfactory, we believe that the natural history of this condition is most favorably altered by surgical treatment.

Thirty-five children under 16 years of age were prepared for pericardiectomy on account of constrictive pericarditis; three died in the immediate preparatory period. Pericardiectomy was undertaken in 32; in 28 the cause was tuberculous. The purpose of this report is to draw attention to the high incidence of constrictive pericarditis in African children in Natal.

Although the removal of hair as a pre-operative preparation of the skin is desirable, it need only be removed over an area limited to a planned incision, and then only in hirsute patients. The use of a depilatory cream as an alternative to a razor would seem to have the advantages of increasing patient comfort; of avoiding injuries inflicted by even skilful shaving; and perhaps of diminishing the incidence of wound infection, without significant risk of reaction to the depilatory. Routine extensive pre-operative hair removal in all patients is unnecessary.