Common surgical training program: standardization of learning quality. / Programa de formación quirúrgica común: uniformidad en la calidad del aprendizaje.

INTRODUCTION: The various surgical specialties in our center have used the simulation and experimental surgery resources available for their training tasks in minimally invasive surgery (MIS) in an individualized manner. With this learning model, a great dispersion of effort and expense was observed, so it was decided to create a unified program based on the following: shared learning, synergy among specialties, moderation of the economic cost, and rational use of the facilities. OBJECTIVE: To describe and assess our consensually designed training program in order to consolidate a shared learning strategy that will enable our residents to acquire and perfect surgical skills in MIS. MATERIALS AND METHODS: The program consists of various increasingly complex phases implemented on a continuous basis throughout the period of specialized training in the virtual laboratory and experimental operating room. The assessment methods were based on quantifiable criteria: percentage of efficiency and completion time of the "McGill Inanimate System for Training and Evaluation of Laparoscopic Skills" (MISTELS) exercises at the beginning and end of the program. An economic study was also conducted. RESULTS: 20 residents have completed the program. Mean times show a significant reduction in each of the exercises. The efficiency percentages at the end of the program were higher than at the beginning (p < 0.001). The cost of the program represented a saving of 67.89%. CONCLUSION: The new MIS training program improved the quality of learning in a safe environment, establishing common criteria among the different specialties and an improved use of resources.

INTRODUCCION: Las diferentes especialidades quirúrgicas de nuestro centro han usado los recursos de simulación y cirugía experimental para sus tareas de formación en cirugía mínimamente invasiva (CMI) de manera individualizada. Con este modelo de aprendizaje se detectó una gran dispersión de esfuerzos y gasto, por lo que se decidió crear un programa unificado basado en: aprendizaje compartido, sinergia entre especialidades, moderación del coste económico y uso racional de las instalaciones. OBJETIVO: Describir y evaluar nuestro programa de entrenamiento diseñado por consenso de cara a la consolidación de una estrategia de aprendizaje compartido que permita a nuestros residentes adquirir y perfeccionar habilidades quirúrgicas en CMI. MATERIAL Y METODOS: El programa consta de diferentes fases con complejidad creciente desarrolladas durante todo el periodo de formación especializada de forma continuada en laboratorio virtual y quirófano experimental. Los criterios de evaluación se basaron en criterios cuantificables: porcentaje de eficiencia y tiempo de realización de los ejercicios de McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) al inicio y final del programa. Se realizó también el estudio económico. RESULTADOS: Han completado el programa 20 residentes. Los tiempos medios demuestran una reducción significativa en cada uno de los ejercicios. Los porcentajes de eficiencia al final fueron mayores que al inicio del programa (p < 0,001). El coste del programa supuso un ahorro del 67,89%. CONCLUSION: El nuevo programa de entrenamiento en CMI mejoró la calidad de aprendizaje en un entorno seguro, estableciendo criterios comunes entre las diferentes especialidades y un mayor aprovechamiento de los recursos.

Programa de formación quirúrgica común: uniformidad en la calidad del aprendizaje / Common surgical training program: standardization of learning quality

Introducción: Las diferentes especialidades quirúrgicas de nuestrocentro han usado los recursos de simulación y cirugía experimentalpara sus tareas de formación en cirugía mínimamente invasiva (CMI)de manera individualizada. Con este modelo de aprendizaje se detectóuna gran dispersión de esfuerzos y gasto, por lo que se decidió crear unprograma unificado basado en: aprendizaje compartido, sinergia entreespecialidades, moderación del coste económico y uso racional de lasinstalaciones. Objetivo: Describir y evaluar nuestro programa de entrenamientodiseñado por consenso de cara a la consolidación de una estrategia deaprendizaje compartido que permita a nuestros residentes adquirir yperfeccionar habilidades quirúrgicas en CMI. Material y métodos: El programa consta de diferentes fases concomplejidad creciente desarrolladas durante todo el periodo de forma-ción especializada de forma continuada en laboratorio virtual y quiró-fano experimental. Los criterios de evaluación se basaron en criterioscuantificables: porcentaje de eficiencia y tiempo de realización de losejercicios de McGill Inanimate System for Training and Evaluation ofLaparoscopic Skills (MISTELS) al inicio y final del programa. Se realizótambién el estudio económico. Resultados: Han completado el programa 20 residentes. Los tiem-pos medios demuestran una reducción significativa en cada uno de losejercicios. Los porcentajes de eficiencia al final fueron mayores queal inicio del programa (p < 0,001). El coste del programa supuso unahorro del 67,89%. Conclusión: El nuevo programa de entrenamiento en CMI mejoróla calidad de aprendizaje en un entorno seguro, estableciendo criterioscomunes entre las diferentes especialidades y un mayor aprovechamientode los recursos.(AU)

Introduction: The various surgical specialties in our center haveused the simulation and experimental surgery resources availablefor their training tasks in minimally invasive surgery (MIS) in anindividualized manner. With this learning model, a great dispersionof effort and expense was observed, so it was decided to create aunified program based on the following: shared learning, synergyamong specialties, moderation of the economic cost, and rationaluse of the facilities. Objective: To describe and assess our consensually designed train-ing program in order to consolidate a shared learning strategy that willenable our residents to acquire and perfect surgical skills in MIS. Materials and methods: The program consists of various increas-ingly complex phases implemented on a continuous basis throughout theperiod of specialized training in the virtual laboratory and experimentaloperating room. The assessment methods were based on quantifiablecriteria: percentage of efficiency and completion time of the “McGillInanimate System for Training and Evaluation of Laparoscopic Skills”(MISTELS) exercises at the beginning and end of the program. Aneconomic study was also conducted. Results: 20 residents have completed the program. Mean timesshow a significant reduction in each of the exercises. The efficiencypercentages at the end of the program were higher than at the begin-ning (p < 0.001). The cost of the program represented a saving of67.89%.(AU)

Bronchoalveolar lavage versus bolus administration of lucinactant, a synthetic surfactant in meconium aspiration in newborn lambs.

This study was designed to study effects of lung lavage versus the classical bolus instillation with a peptide-based synthetic surfactant (lucinactant) in a model of Meconium Aspiration Syndrome (MAS). Eighteen newborn lambs received meconium and were randomized to: the experimental meconium installation (eMAS) group-lambs with eMAS kept on conventional mechanical ventilation (control); the SF-Bolus group-eMAS receiving a lucinactant bolus (30 mg/ml); or the D-SF-Lavage group-eMAS treated with dilute lucinactant bronchoalveolar lavage (10 mg/ml). Systemic and pulmonary arterial pressures, blood gases, and pulmonary mechanics were recorded for 180 min. In addition, the intrapulmonary distribution of the lucinactant was determined using dye-labeled microspheres. Following meconium instillation, severe hypoxia, hypercapnia, acidosis, and pulmonary hypertension developed, and dynamic compliance decreased (50% from baseline). After lung lavage with dilute lucinactant, gas exchange significantly improved versus bolus instillation (P < 0.05). Further, only in the lavage group did pulmonary arterial pressure return to basal values and dynamic compliance significantly increased. Both lung lavage and bolus techniques for the administration of lucinactant resulted in a non-uniform lung distribution. In conclusion, in newborn lambs with respiratory failure and pulmonary hypertension induced by meconium, lung lavage with dilute lucinactant seems to be an effective and safe alternative for treatment for MAS.

Hypoxic-ischemic injury in the immature brain--key vascular and cellular players.

Over the past decade, much has been learned about the cellular and molecular mechanisms underlying hypoxic-ischemic (H-I) injury in the preterm human brain. The pathogenesis of H-I brain injury is now understood to be multifactorial and quite complex, depending on (i) the severity, intensity and timing of asphyxia, (ii) selective ischemic vulnerability, (iii) the degree of maturity of the brain, and (iv) the characteristics of the ensuing reoxygenation/reperfusion phase. Each of these factors has differential effects on the distinct cell populations in the brain, with certain specific cell types being particularly vulnerable in the developing brain. In this review, we discuss the role of the blood vessels and the distinct cell populations, which are the mayor constitutive elements of the immature brain, in the pathophysiology of H-I lesion. The presence of fragile and poorly anastomosed blood vessels and the existence of disturbances in the blood-brain barrier alter blood flow, vascular tone and nutrient delivery. Brain cells are sensitive to the overstimulation of neurotransmitter receptors, particularly glutamate receptors, which can provoke excitotoxicity leading to the death of neurons and other cells such as astrocytes and oligodendrocyte progenitors. Microglial activation by means of excitatory amino acids and by leukocyte migration initiates the inflammatory response giving rise to an increase in regional cerebral blood flow and promoting astrocyte and oligodendrocyte injuries. A better understanding of these aspects of H-I injury will contribute to more efficient strategies for the management of the associated damage.

The cardiovascular effects of partial liquid ventilation in newborn lambs after experimental meconium aspiration.

OBJECTIVE: To study the effects of partial liquid ventilation with perfluorocarbon on cardiovascular function, pulmonary gas exchange, and lung mechanics in term newborn lambs with pulmonary hypertension induced by tracheal instillation of human meconium. DESIGN: Prospective, randomized study. SETTING: Research Unit at a university-affiliated hospital. SUBJECTS: Twelve term newborn lambs (<6 days old). INTERVENTIONS: Lambs were studied in two groups (n = 6): meconium aspiration (3-5 ml/kg 20% meconium solution) managed on pressure-limited conventional mechanical ventilation with or without partial liquid ventilation with perfluorocarbon. MEASUREMENTS AND MAIN RESULTS: Heart rate, systemic and pulmonary arterial pressures, arterial pH and blood gases, cardiac output, and pulmonary mechanics were measured. Partial liquid ventilation in term newborn lambs with experimental meconium aspiration did not alter cardiovascular profile: heart rate, systemic arterial pressure, and cardiac output maintained initial values throughout the experiment. There was a significant improvement in gas exchange (oxygenation increased from values of <100 torr to 338 torr, and ventilation reached normal values in 15 mins). Dynamic compliance increased in 30 mins, reaching basal values (1.1 +/- 0.3 ml/cm H(2)O per kg). Despite the good response (blood gases and cardiovascular profile) to partial liquid ventilation in meconium aspiration syndrome, pulmonary hypertension did not decrease. CONCLUSIONS: Partial liquid ventilation with perfluorocarbon could be a good noninvasive alternative technique that improves gas exchange and pulmonary mechanics in meconium aspiration syndrome without impairing cardiovascular function.

[Congenital heart defects with tracheal and bronchial stenoses: surgical treatment with extracorporeal circulation]. / Cardiopatías congénitas con estenosis traqueales y bronquiales: tratamiento quirúrgico con circulación extracorpórea.

We present our experience with the surgical management of congenital cardiac defects when tracheal or bronchial stenosis is present. Concerning pulmonary artery sling, we think that it is necessary to correct the cardiac malformation and trachea-bronchial stenosis at the same time. After surgical correction, if the patient cannot be weaned from mechanical ventilation (10-15 days), it is mandatory to rule out the presence of tracheo-bronchial tree lesions in order to perform surgery without delay. The operation should be performed under cardiopulmonary by-pass at the same time as the surgical correction of the cardiac malformation. We believe that the best technique for localized obstruction is resection of the stenotic area, followed by termino-terminal anastomosis (one case in our patient group). However, when the length of the obstruction is longer, our election is to enlarge the stenotic area with pre-molded cartilage (four cases).

[Surgical treatment of Fallot's tetralogy with hyperplasia or agenesis of the conal septum]. / Tratamiento quirúrgico de la tetralogía de Fallot con hipoplasia o agenesia del septo conal.

INTRODUCTION: The clinical evolution, anatomosurgical aspects, and postoperative evolution of a specific group of Fallot's tetralogy with hipoplasic or agenesic of the conal septum (representing a 7% of our Fallot's tetralogy cases) is presented. METHODS: A total of 41 patients surgically corrected in our Service between February 1973 and December 1995 has been retrospectively studied. Ages ranged between 13 months and 13 year. Clinically all cases developed moderate or severe hypoxemia. In 43.9% of cases it was necessary to perform a palliative surgery at an age between 15 days and 4 years. RESULTS: There was no hypoxemics spells. In the ECG we have found a QS in the aVR in 40% of cases. There was 7 deaths (17% of mortality rate). Four cases required reoperation. The clinical evolution, ECG, EKO, and hemodynamics findings are commented. CONCLUSIONS: In this type of Fallot's tetralogy, specifically in those cases with a pulmonary artery ring of normal size, it is necessary to have a good preoperative diagnoses in order to perform a longitudinal ventriculotomy with right ventricular outflow tract enlargement. Also, it is important to be meticulous with the stitches in the closure of the ventricular septal defect with a patch in order to avoid the potential lesion of the aortic valve.

[The treatment of the tracheobronchial stenosis by extracorporeal circulation]. / Tratamiento de las estenosis traqueo-bronquiales mediante circulación extracorpórea.

Six children with tracheobronchial stenosis secondary to cardiovascular ring were operated with extracorporeal surgery. Three of them with pulmonary sling had a tracheobroncoplasty with costal cartilage, one with xiphoides appendix and another with pericardio. One girl 2 years old was operated resecting three tracheal rings and anastomosis end to end. The child that was operated with pericardio died with infection and sepsis three months after the operation. The other five are well five, four and two years after plasty.

[Extracorporeal membrane oxygenation (ECMO). II. The development of an experimental model in newborn lambs]. / Oxigenación por membrana extracorpórea (ECMO). II. Desarrollo de un modelo experimental en corderos recién nacidos.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is a technique used for cardiorespiratory support in the treatment of newborns with severe respiratory insufficiency. ECMO has not been used yet in newborns in Spain. The aim of this work was to develop an experimental veno-arterial ECMO model in newborn lambs for training the NICU medical and nursing staff before the clinical application of this technique. MATERIAL AND METHODS: Six newborn lambs were anesthetized, traqueotomized and connected to a neonatal ventilator. The right jugular vein and left carotid artery were cannulated and the catheters were located in the right atrium and aortic arch, respectively. A venous-arterial ECMO was performed during three hours, with an experimental ECMO circuit developed by us. Arterial pH and blood gases, systemic and airway pressures, heart rate, and rectal temperature were monitored. RESULTS: The experimental ECMO circuit developed by use had a very low cost, but was capable of maintaining adequate gas exchange, acid-base balance and a normal rectal temperature. CONCLUSIONS: The development of an experimental ECMO model in newborn lambs may allow the establishment of an initial training program and to maintain the expertise of the NICU staff of a perinatal center planning to start an ECMO program.

[Tetralogy of Fallot: total repair in the first year of life]. / Tetralogía de Fallot: corrección total en el primer año de vida.

OBJECTIVE: Since the first correction of tetralogy of Fallot in 1955, the optimal age for total correction has been in continuous debate and remains a controversy. PATIENTS AND METHODS: Here we present our experience with 44 patients with tetralogy of Fallot which was surgically corrected in the first year of life. In 37 cases total correction was achieved with the first operation. In the remaining 7 cases previous palliative surgery was performed. Details of surgical decision making, hemodynamic data and surgical procedure are described in detail. RESULTS: There were 8 deaths (18.1% mortality rate). There were no deaths in the last 24 consecutive cases. Complications, need for reoperation and long-term follow-up of the 36 survivors are discussed. CONCLUSIONS: After a detailed analysis of both results and follow-up, our surgical criteria is described, with the intention of performing palliative surgery in only a restricted number of cases of tetralogy of Fallot where the anatomy is unfavorable for total correction with a single intervention.

[Continuous hemofiltration. Development of an experimental model]. / Hemofiltración continua. Desarrollo de un modelo experimental.

OBJECTIVE: Continuous hemofiltration is an extracorporeal technique used to eliminate water and solutes by convective transport through a hemofilter. The aim of this study was to develop an experimental model of arterio-venous and veno-venous continuous hemofiltration in order to gain experience before its clinical application in human neonates. MATERIALS AND METHODS: Twelve white New Zealand adult rabbits were anesthetized, tracheotomized and connected to a continuous flow neonatal ventilator. Continuous arterio-venous hemofiltration (n = 6) was performed via catheters placed in the carotid artery and jugular vein and veno-venous hemofiltration (n = 6) by a double-lumen catheter located in the inferior vena cava. Heart rate, arterial pressure, pH and blood gases, and the volume of ultra-filtrate were monitored and recorded for a three hour period. RESULTS: In both groups a high rate of ultrafiltration was achieved. The volume of ultrafiltration decreased somewhat during the second hour and remained stable thereafter. No hemodynamic changes were detected. CONCLUSIONS: The development of an experimental model for continuous arterio-venous and veno-venous hemofiltration in rabbits, facilitated the implantation of these techniques in human neonates. The model may be used to train the staff of the Neonatal Intensive Care Unit and to eliminate difficulties with vascular access and the care of extracorporeal lines.

[Technical innovations in total extracardiac cavo-pulmonary connection in Fontan-type operation. An experimental study and first 2 operated clinical cases with excellent immediate results]. / Innovaciones técnicas de la conexión cavo-pulmonar total extracardíaca en la cirugía tipo Fontan. Estudio experimental y dos primeros casos clínicos operados con excelentes resultados inmediatos.

INTRODUCTION: Three technical modalities are presented with total extracardiac cava-pulmonary connection, with bidirectional Glenn, as coverage of this type of extracardiac connection for all types of cardiopathies suitable for Fontan type correction. METHODS: Development of an experimental protocol for the perfecting of the three technical variants tested: "Tunnel from inferior cava to right pulmonary artery by means of right atrial wall and vascularized pericardium", "Tunnel from inferior cava to the trunk of the pulmonary artery with or without pulmonary valve with P.T.F.E. hemiconduit" and "Tunnel from inferior cava to the pulmonary graft as a artery with P.T.F.E. graft as a hemiconduit". RESULTS: The first two clinical cases operated on using the third technical variant are presented. Both cases evolved during immediate postoperative period with a very favourable hemodynamic response, with pressures at conduit and P.A. level of 10-12 mmHg, normal cardiac output and sinus rhythm. The later clinical evolution in both cases is very satisfactory. The five cases published by Laschinger with this same technique showed a very favourable evolution during the immediate postoperative period and later. CONCLUSION: The technical facility of its performance, the slight traumatism of this surgery, the important technical advantages with respect to the total cava-pulmonary intraauricular connection and the good initial hemodynamic results make us consider the total extracardiac cava-pulmonary connection as an important contribution in this type of surgery. It is clear that time and greater clinical experience with this type of connection is required for the correct evaluation of all and each one of the numerous theoretical advantages shown and in order to detect possible disadvantages.

[Vascular rings of aortic origin: the surgical experience in 43 cases]. / Anillos vasculares de origen aórtico: experiencia quirúrgica en 43 casos.

INTRODUCTION AND OBJECTIVES: Aortic vascular rings can produce compression and obstruction in the airway and/or esophagus early surgical treatment in the first days or months of life. The reported incidence range between 0.3-0.6% with an 0.5% in our series. The following is a retrospective analysis with clinical, radiological and angiocardiographic study of the patients operated on in our service with the diagnosis of aortic vascular ring focused on the surgical results. METHODS: A total of 43 children with ages ranging between 21 days and 10 years (mean age 17 months) underwent surgical treatment for aortic vascular ring, during the period between january 68 and january 94. Clinically, 74% had stridor, 27.4% gastroesophageal reflux, 34% pulmonary infection, 14% respiratory insufficiency with mechanical ventilation, 12% heart failure, 9% dysphagia, 2% crisis of bronchospasm and 2% tracheomalacia that require tracheotomy prior to surgical correction. Diagnosis was made by esophagogram 86% of the cases. Aortography as the late diagnosis method or for election to surgical approach was made in 85% of the cases. In 42% were double aortic arch, 32% anomalous right subclavian artery and 25% right aortic arch with left ductal ligamentum. RESULTS: Reoperation was performed in 4 cases. Two early (1 case for hemorrhage, 1 case for phrenic paralysis requiring diaphragmatic plication), and two late reoperations (1 aortopexy, 1 tracheal termino-terminal anastomosis) at 2 and 13 months respectively. Hospital mortality was 1 case (2%) with 1 additional late death (2%). Follow-up was performed in the remaining 39 cases with a mean of 11 years (ranging between 1 and 25 years. Thirty seven of 41 patients alive asymptomatic (90%). CONCLUSIONS: Due to a low mortality rate (2.3%) not related with the age of the patient at the moment of the surgical procedure based in our experience, we conclude that it is very important to perform both, early diagnosis and surgical treatment in order to avoid the potential residual lesion on the airway caused by tracheo-broncho malacia, in order to avoid the deleterious effect on the results both at early and later follow-up.

[Severe malformations associated with congenital diaphragmatic hernia: conditioning factors for mortality]. / Malformaciones mayores asociadas a la hernia diafragmática congénita: condicionantes de la mortalidad.

We have retrospectively reviewed the clinical records of 42 newborns with congenital diaphragmatic hernia (CDH) treated in our Neonatal Unit between January 1974 and December 1991. In 20 of the children, the CDH was associated with other malformations, which were major in 11 cases (26.2%). The malformations which occurred most frequently were cardiovascular, followed by chromosomal anomalies and those affecting the central nervous system (CNS). All of the newborns with major malformations are included in the high risk group or those with early diagnosis. Overall mortality was 57.1%. Nine out of the 11 cases with major malformations died (81.8%).

[Long-term results of surgical management of congenital aortic stenosis]. / Resultados a largo plazo de la estenosis aórtica congénita operada.

This retrospective study and review of the literature was undertaken to assess the long term results of valvotomy in congenital aortic stenosis (AS). One hundred and seven patients, aged between 14 days and 15 years (mean: 6.2 years), were operated on between 1966 and 1989. Thirty-three cases had valvular AS, 48 discrete subvalvular AS, 10 supravalvular AS and 16 combined AS. Thirty-three patients had associated cardiac anomalies. The surgical mortality was 6.5% (3.5% in children over 2 years of age). Three patients were lost. Ninety-seven patients had a follow-up period between 6 months and 16 years (mean: 5.4 years) with an actuarial survival of 95% at the age of 15 years. There were adverse events in 39 patients: AS, aortic regurgitation, bacterial endocarditis, third-degree heart block. Thirteen patients required re-operation and 4 balloon valvuloplasty; the late mortality was 5%. We conclude that this surgery has a low surgical mortality, but must be considered as palliative in most cases.

[Left subclavian-pulmonary trunk fistula with a vascular prosthesis as palliative treatment in Fallot conditions]. / Fístula subclavia izquierda-tronco pulmonar con prótesis vascular como tratamiento paliativo de las situaciones de Fallot.

In this paper, our experience with a new systemic-to-pulmonary artery shunt: subclavian-pulmonary artery trunk shunt with PTFE (central shunt) is presented. Between November 1985 and March 1990 this central shunt was employed in 8 children with ages ranged between 4 days and 3 years, and weights between 2 and 12 kg. Diagnosis were Fallot's tetralogy in three; pulmonary atresia with intact septum in three; complete AV canal and Fallot's tetralogy in one, and univentricular heart and pulmonary atresia in 1 patient. There were no surgical deaths. Hospital mortality was present in 1 case (AV canal and Fallots tetralogy) at the moment of reoperation 1 month later. Follow-up ranged between 2 and 46 months. One case, pulmonary atresia with intact septum, has undergone total correction. The remainder 6 cases are in good situation with O2 saturation above 70%. This central shunt has the advantages to provide a bidirectional blood flow to both pulmonary branches avoiding the risk of direct damage in the pulmonary arteries found with the conventional aorto-pulmonary shunts.

[Anatomy and surgical implications of incomplete forms of atrioventricular septal defects]. / Anatomía e implicaciones quirúrgicas de las formas incompletas de defectos del septo atrioventricular.

We present an anatomic intraoperative study of 93 consecutive operated cases with an ostium primum defect. The type of the ostium primum, size of interauricular defect, position of the coronary sinus, tricuspid valve, mitral valve and subvalvular apparatus, are analyzed. Inside the mitral valve apparatus, the size, form, type and number of clefts are described as well as septal valve anomalies. We point out the importance of performing a detailed and fast anatomic study within a surgical protocol to obtain the optimal anatomic correction of the cardiopathy.

[Surgery of symptomatic interauricular communication in the first year of life]. / Cirugía de la comunicación interauricular sintomática en el primer año de la vida.

Symptomatic atrial septal defect (ASD) is rare in infancy and even more is symptomatic ASD requiring surgery at that age (13.7% and 3.7% respectively in our series). Our experience on surgery for symptomatic ASD in infancy with 6 cases out of 161 consecutive ASD surgically corrected during an experience of 17 years is presented. Ages ranged between 5 and 11 months (9.5 +/- 2.5 months) and weight between 4 and 6.400 kg (5.3 +/- 0.8 kg). In all cardiomegally was present with cardiothoracic ratio between 0.6 and 0.7 in 4 and over 0.7 in the remainder two cases. Isolated ASD was present in 3 cases, associated partial anomalous pulmonary venous drainage ein 3 and additional ventricular septal defect in one. Mortality was present in one case due to hypoplasia of the left ventricular cavity. Follow up ranged between 30 and 156 months with a cumulative follow up of 442 months, mean 88.4 +/- 50.8 months/patient. Clinically all are asymptomatic without medication. Clinical and hemodynamic data file, surgery complications and possible risk factors for development symptomatology in the ASD in infancy are widely commented.