[Indications of lung transplantation: Patients selection, timing of listing, and choice of procedure]. / Indications de la transplantation pulmonaire : sélection des candidats, critères d'inscription en liste d'attente, choix du type d'intervention.

Lung transplantation (LT) is now considered as an excellent treatment option for selected patients with end-stage pulmonary diseases, such as COPD, cystic fibrosis, idiopathic pulmonary fibrosis, and pulmonary arterial hypertension. The 2 goals of LT are to provide a survival benefit and to improve quality of life. The 3-step decision process leading to LT is discussed in this review. The first step is the selection of candidates, which requires a careful examination in order to check absolute and relative contraindications. The second step is the timing of listing for LT; it requires the knowledge of disease-specific prognostic factors available in international guidelines, and discussed in this paper. The third step is the choice of procedure: indications of heart-lung, single-lung, and bilateral-lung transplantation are described. In conclusion, this document provides guidelines to help pulmonologists in the referral and selection processes of candidates for transplantation in order to optimize the outcome of LT.

[Anaesthetic approach of paediatric pulmonary hypertension]. / Anesthésie et hypertension artérielle pulmonaire chez l'enfant en chirurgie non cardiaque.

Paediatric pulmonary arterial hypertension (PAH) is a challenge for the paediatric anaesthetist. Due to its high morbidity and mortality, support should be provided by a dedicated team. Understanding the pathophysiology of PAH allows performing an appropriate therapeutic approach. In case of high vascular pulmonary resistance, the main objectives of anaesthetic management are to maintain an optimal pulmonary flow and to avoid the decrease in systemic arterial pressure. Haemodynamic monitoring is essential to detect the onset of an acute PAH crisis but also to give direct information on the efficacy of treatment.

[Venous air emboli in a 4 year old child]. / Embolie gazeuse d'origine veineuse chez un enfant.

A 4 year old girl is referred to our institution for resection of a nephroblastoma with an extension of the tumor into the lumen of the inferior vena cava. To perform a correct resection of the tumor, the operation was conducted under cardiopulmonary bypass. At the end of the procedure, a bilateral mydriasis was noticed. A CT-scan concluded to a massive venous air emboli. As the procedure was unventful, and no other cause of air emboli was found, the etiology of this emboli is problably retrograde because of the large opening of the inferior vena cava that was required to remove the tumor. To avoid similar case the use of transcranial doppler monitoring may be of interest.

[How can we optimize medical orderings in intensive care unit (ICU)?]. / Optimisation des prescriptions en réanimation.

OBJECTIVES: To evaluate whether intensivists would accept to optimize their orderings of biological samplings, x-rays and target drugs and to assess the consequence on patient's outcome. STUDY DESIGN: Monocentric evaluation of medical economic procedure. METHODS: Meetings of consultants, registrars and residents started on Dec 21, 2006 with two to three sessions a year in order to evaluate the process of medical ordering. The physicians and pharmacists gave the results of orderings at each meeting. Orderings of systematic samplings, bedside x-rays and unjustified expansive drugs were discouraged, but target samplings and lung ultrasonography were encouraged. New residents were systematically taught about this programme. Meanwhile, monthly morbidity-mortality meetings were pursued in order to assess the consequences of this politics. RESULTS: While ICU total production increased by 3.4% and potentially evitable deaths decreased by 34%, annual expenses decreased by approximatively € 777,000 from 2006 to 2008. This was due to decreased orderings in biology by 30%, bedside x-rays by 10%, computed tomographic scans by 16% and target drugs by 35%. However, an increased ordering in four target drugs was observed in 2008 as compared with 2007. CONCLUSION: Multidisciplinary optimization of medical ordering can be efficient in ICU. However, a profit-sharing with ordering physicians would be necessary to prolong these effects.

[Clinical usefulness of new-generation pulse oximetry in the paediatric cardiac surgery setting]. / Utilisation clinique d'un oxymètre de pouls de nouvelle génération dans le cadre de la chirurgie cardiaque pédiatrique.

OBJECTIVES: Arterial oxygen saturation (SaO(2)) monitoring using pulse oximeter (SpO(2)) is mandatory in the intensive care unit. The aim was to assess bias and precision of new (SpO(2)ng) and old (SpO(2)og) pulse oximeter technologies in the postoperative period following pediatric cardiac surgery in cyanotic children. STUDY DESIGN: Prospective, monocentric. PATIENTS AND METHODS: Ten patients (7 days to 53 months old) were studied in the postoperative period following palliative cardiac surgery. SaO(2), SpO(2)og, and SpO(2)ng were obtained every 4 hours. SaO(2) of arterial blood sample was obtained from an intra-arterial catheter located in the radial artery, on the same side as the oximeters. Bias and precision were assessed using Bland-Altman analysis. RESULTS: We obtained 136 SaO(2) determinations. Mean SaO(2) was 76+/-15%. SpO(2)og was significantly different from SaO(2), while SpO(2)ng was not different from SaO(2). In 21 (15%) cases, SpO(2)og was not available whereas SpO(2)ng was available in 136 (100%) cases. In the remaining 115 cases, SpO(2)ng's precision was significantly better than SpO(2)og's precision. DISCUSSION: SpO(2)ng is more accurate and more reliable than SpO(2)og for SaO(2) monitoring in the postoperative period following pediatric cardiac surgery in cyanotic children.

[Anaesthesia for non cardiac surgery in patients with grown-up congenital heart disease]. / Anesthésie pour chirurgie non cardiaque chez le patient adulte porteur d'une cardiopathie congénitale.

OBJECTIVES: To be aware of the different grown-up congenital heart diseases. To know their physiopathology, adverse events and the way to manage patients presenting with these pathologies in the anaesthesia for non cardiac surgery setting. DATA SOURCE: References were obtained from Pubmed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: congenital heart disease, congenital cardiac disease, atrial septal defect, ventricular septal defect, Eisenmenger syndrom, cavopulmonary shunt, tetralogy of fallot, endocarditis. DATA SYNTHESIS: Nowadays, there are equal numbers of adults and children with congenital heart disease. These patients can be divided into three different groups: patients with corrective surgery, patients with palliative surgery, and patients with uncorrected congenital heart disease. In the non cardiac surgery setting, anaesthetists will have to cope with increasing number of adult patients with grown-up congenital heart disease. Because of the complexity and the severity of these lesions it is highly recommended to contact referral centers for the management of these patients. The most frequent complications in this setting are: arrhythmia, hypoxia, cardiac failure, and paradoxal air embolism. Anaesthesia management in this setting requires perfect comprehension of the physiology and anatomy. For the most severe pathologies, it is recommended to refer these patients to referral centres.

[To understand blood pressure and heart rate variability]. / Comprendre la variabilité de la pression artérielle et de la fréquence cardiaque.

OBJECTIVES: To review current data on the heart rate and blood pressure variability. DATA SOURCES: Search through Medline databases of articles in french or english. DATA SELECTION: Original articles and case reports were selected according to their quality and main advances. The articles were analysed in order to obtain current data about the methods of study and clinical application of blood pressure and heart rate variability. DATA SYNTHESIS: Various regulatory systems in the cardiovascular system play crucial roles in controlling and assuring adequate perfusion of the peripheral tissues. Among them the baroreceptor reflex is the most important regulatory mechanism in the short-term control of the heart rate and blood pressure, and operates through the autonomic nervous system. The gain of the cardiac baroreflex further referred to, as baroreflex sensitivity is an interesting way to study this system. Unfortunately, with our current knowledge, it is not possible to predict the instantaneous output of the baroreceptor in response to instantaneous changes in input within a frequency range of physiological importance. The fast Fourier transform can describe variables as the sum of elementary oscillatory components and it has been established as practical clinical methods for detecting abnormalities in cardiovascular control. A time-frequency distribution provides an indication of how the spectral energy distribution varies with time and it is an interesting tool in non-stationary data. One of the major motivations behind spectral analysis is the hope that the combination of time-domain and frequency-domain analyses will provide dynamical informations about the relation between blood pressure and heart rate.

Hipertensión pulmonar: el papel del óxido nítrico en adultos / Pulmonary hypertension: the role of nitric oxide in adults

El cuerpo humano libera óxido nítrico (ON) endógeno desde tres fuentes principales: neuronas, procesos inflamatorios (ON inducido) y desde el endotelio. La industria química produce ON reaccionando dióxido sulfúrico con ácido nítrico, o nitrito de sodio con ácido sulfúrico, o mediante la oxidación de amonio. El ON inhalado actúa en la célula muscular lisa del endotelio pulmonar produciendo relajación a través de la estimulación de la guanilato-ciclasa. La vida media corta del ON y su inmediata destrucción en metabolitos, hemodinámicamente inactivos pero tóxicos, hacen de este fármaco un vasodilatador pulmonar selectivo que puede disminuir la presión arterial pulmonar, mejorando la fracción de eyección del ventrículo derecho a la vez que disminuye el cortocircuito intrapulmonar, mejorando la oxigenación.El ON ha demostrado su utilidad en el tratamiento del fracaso ventricular derecho secundario a hipertensión pulmonar en el postoperatorio de cirugía cardíaca y especialmente en el paciente trasplantado. Las dosis utilizadas habitualmente oscilan entre 5 y 20 partes por millón (ppm). Sin embargo, se ha descrito una gran variabilidad individual de respuesta al ON. Entre un 30 y un 40 por ciento de los pacientes no responden al tratamiento.También se utiliza para valorar la reversibilidad de la hipertensión pulmonar crónica en pacientes candidatos para trasplante de corazón. Se han sugerido otras utilidades, como la reversión de la vasoconstricción pulmonar inducida por la protamina. Las principales limitaciones a su uso son la toxicidad de sus metabolitos y la vía de administración (AU)

[Pulmonary hypertension: the role of nitric oxide in adults]. / Hipertensión pulmonar: el papel del óxido nítrico en adultos.

The human body releases endogenous nitric oxide (NO) from three main sources: neurons, inflammatory processes (induced NO) and endothelium. The chemical industry produces NO by reacting sulfur dioxide and nitric acid, or sodium nitrite and sulfuric acid, or by oxidation of ammonia. Inhaled NO acts on smooth muscle cells of the pulmonary endothelium, causing relaxation by stimulation of guanylate-cyclase. The short half life of NO and its immediate breakdown into hemodynamically inactive but toxic metabolites make this drug a selective pulmonary vasodilator that can decrease pulmonary arterial pressure, improving right ventricular ejection fraction while decreasing intrapulmonary shunt and improving oxygenation.NO has demonstrated its usefulness in treating right ventricular failure secondary to pulmonary hypertension after heart surgery, especially in the transplanted patient. Doses have usually ranged from 5 to 20 parts per million. However, great individual variability in response to NO has been reported. Between 30 and 40% of patients do not respond to treatment. NO is also used to assess the reversibility of chronic pulmonary hypertension in patients who are candidates for heart transplants. Other uses have been suggested, such as reversion of pulmonary vasoconstriction induced by protamine. Applications are limited by the toxicity of metabolites and by route of administration.

Glucose versus lactated Ringer's solution during pediatric cardiac surgery.

OBJECTIVE: Whether intraoperative fluid infusion should contain glucose during pediatric cardiac surgery remains controversial. This study was performed to compare the effects of glucose and glucose-free solutions on blood glucose and blood insulin levels during total repair of congenital heart diseases. DESIGN: Prospective randomized and blinded study. SETTING: Cardiovascular university center. PARTICIPANTS: Forty nondiabetic children, weight ranging from 4 to 10 kg, scheduled for cardiac surgical procedures requiring cardiopulmonary bypass (CPB) without total circulatory arrest. INTERVENTIONS: Group R (n = 20) was administered lactated Ringer's solution intraoperatively, and group G (n = 20) received 5% glucose. Fluids were infused at a rate of 3 mL/kg/h in the two groups from the induction of anesthesia to the end of the surgical procedure. Blood glucose and insulin were sampled before infusion (Tzero), before CPB (T1), 10 minutes after initiation of CPB (T2), 10 minutes after initiation of rewarming (T2), and at the end of the procedures (T4). Postoperatively, blood glucose was measured at the first, 12th, and 24th hours. MEASUREMENTS AND RESULTS: During the prabypass period, three children in group R had severe hypoglycemia (blood glucose < 40 mg/dL). After initiation of CPB, blood glucose increased in both groups, with a small difference at the end of the procedure. No infants in the two groups had blood glucose higher than 239 mg/dL. CONCLUSIONS: Glucose withdrawal during pediatric cardiac surgery induces threatening hypoglycemia during the prabypass period, and moderate intraoperative glucose administration (2.5 mg/kg/min) is not responsible for major hyperglycemia.

Effects of hypothermia on cochlear micromechanical properties in humans.

The aim of the present experiment was to investigate the influence of hypothermia on transient evoked otoacoustic emissions (TEOAEs) in humans. Hypothermic alterations were brought about directly by cooling the cardiovascular system of young children during open heart bypass surgery. This condition caused TEOAE levels to decrease with a significant positive correlation between total and frequency band TEOAE amplitudes during cooling. TEOAEs were totally abolished at tympanic temperatures around 30 degrees C, without it being possible to find differences in TEOAE alteration among the frequency components. During rewarming, the changes reversed and TEOAEs returned to their initial prehypothermia status, although sometimes only partially. Despite large possible metabolic changes caused by this hypothermic condition at various levels, it is concluded that the motile properties of outer hair cells (OHCs), that are related to TEOAEs, are temperature-sensitive. The total suppression found in deep hypothermia (above 30 degrees C) could conceivably be attributable to a process involving a temperature-dependent energy source.

Intracardiac air clearing in valvular surgery guided by transesophageal echocardiography.

BACKGROUND AND AIMS OF THE STUDY: Air embolism during open heart surgery seems to be a common occurrence and may be responsible for neuropsychological deficit or myocardial damage. MATERIAL AND METHODS: Forty-two consecutive patients undergoing valvular surgery were studied using the long axis view of the heart by two dimensional transesophageal echocardiography (TEE). The patients were randomized into two groups of 21 each. In group 1, the routine air evacuation method was used. In group 2, the same air evacuation method was used and controlled with a Doppler ultrasonic probe adjusted around the root of the aorta. At the end of air evacuation, intracardiac microbubbles and retained air were analyzed with TEE and when air was founded, its location was communicated to the surgeons who tried to remove it by shaking the heart and tilting the operating table for 15 minutes. The patients were assessed for detection of cardiac or neurological postoperative complications. RESULTS: The incidences of microbubbles and retained air were 57% and 43% in group 1, and 62% and 38% in group 2 respectively (ns). The mean grade of microbubbles was lower in group 2: 1.4 +/- 0.8 vs. 2.2 +/- 0.9, p < 0.05. TEE allowed to significantly decrease (p < 0.05) retained air and mean grade of microbubbles to 14% and 1.3 +/- 0.8 in group 1, and to 10% and 0.8 +/- 0.8 in group 2, without statistical difference between the two groups. Despite the help of TEE, manual attempts to eradicate retained air were unsuccessful in five patients (three in group 1, two in group 2). CONCLUSIONS: The use of aortic ultrasonic probe allowed to reduce the amount of microbubbles. TEE was a useful tool not only for the detection of retained air but also for locating it, and guiding the procedure to eliminate it.

Long-term results of heart transplantation deteriorate more rapidly in patients over 60 years of age.

It is generally agreed that the upper age limit for heart transplantation is 60 years. However, an increasing number of elderly candidates are accepted for heart transplantation. We retrospectively analyzed our experience with a total of 204 consecutive transplantations, performed in 195 adult patients (9 retransplantations) between March 1987 and September 1993. There were 48 patients older than 60 years (mean 62.9 +/- 3), group I (gr I) and 156 patients between 20 and 59 years old (mean 47.5 +/- 8), group II (gr II). The two groups were matched for sex-ratio (female 10.4 vs 14.2%), indications (cardiomyopathy, ischemic, others), and hemodynamic parameters (pulmonary artery pressure, capillary wedge pressure, cardiac index). A ventricular assist device was used in 14 patients as bridge to transplantation in gr II vs 0 to gr I. There were seven early deaths in gr I (14.6%) vs 14 in gr II (8.97%, NS). A total of 183 survivors (41 vs 142) have been followed up for 1 month-6.3 years (mean follow-up 20.4 +/- 19.3 months in gr I, 35.4 +/- 23 in gr II). No patient was lost to follow-up. There were 11 late deaths in gr I vs 16 in gr II. The most common cause was malignancy (n = 4) in gr I and sudden death (n = 9) in gr II, with a significant difference. The actuarial survival was 68.8% in gr I vs 88.5% in gr II at 1 year 43.5% in gr I vs 76.4% in gr II at 5 years. In conclusion, transplanted patients over 60 years of age have a significantly poorer late survival than younger patients, despite similar good early results. Moreover, the causes of late deaths were different in the two groups. So, heart transplantation in patients over 60 years of age should be carefully considered.

Pulsatility improves hemodynamics during fetal bypass. Experimental comparative study of pulsatile versus steady flow.

BACKGROUND: The main advantage of pulsatile flow compared with steady flow during cardiopulmonary bypass is to prevent a rise in systemic vascular resistances. We hypothesized that pulsatile flow could overcome the progressive rise in peripheral and placental vascular resistances observed during fetal bypass and leading to progressive irreversible hypoxemia. METHODS AND RESULTS: A study was undertaken in 17 fetal lambs (110 to 140 days of gestation). Fetal bypass was established for a 30-minute period through right atrial and main pulmonary artery cannulation. The circuit had no oxygenator. Flow was delivered by a standard roller pump for the continuous study (group 1, n = 9) or by a centrifugal pulsatile pump for the pulsatile study (group 2, n = 8). Oxymetric and hemodynamic parameters, along with organ blood flow determined by radiolabeled microspheres counting, were recorded before (T1) and after 10 minutes (T2) and 30 minutes (T3) of bypass. SaO2 and PaO2 were significantly higher in group 2 than in group 1 at T2 but thereafter deteriorated similarly in both groups, whereas PCO2 remained unchanged. Pump flow in group 2 was significantly higher than in group 1 at T2 and T3 (957.6 +/- 49 and 1104 +/- 152 versus 437.6 +/- 23 and 467.8 +/- 43 mL/min, respectively). Systemic vascular resistances during pulsatile bypass were also significantly lower than in group 1 at T2 (402 +/- 12 versus 930 +/- 79 dynes/sec/cm-5) and T3 (374 +/- 60 versus 1017 +/- 192 dynes/sec/cm-5). At T2 and T3, all individual blood flows except the brain but including the placenta were statistically higher in group 2 than in group 1. Placental vascular resistances gradually increased during bypass in group 1 to reach 2.9 +/- 0.2 mm Hg.mL-1.min-1.kg-1 at T3 and remained approximately stable in group 2 during 30 minutes of pulsatile bypass, varying from 0.35 +/- 0.02 to 1.26 +/- 0.14 from T2 to T3 (P < .01). CONCLUSIONS: The data suggest that pulsatile flow for 30 minutes of bypass in a fetal lamb preparation temporarily prevents the progressive hypoxemia observed under steady-flow bypass. Pulsatile flow allows higher pump flow through a significant decrease in systemic vascular resistances. Individual organ blood flow, including placenta, was significantly higher under pulsatile bypass. With technical improvements in the design of pulsatile devices adapted to more physiological beat rates, pulsatility may become a valuable adjunct to overcome placental dysfunction observed during experimental fetal cardiac surgery.

[Causes of failure analysis after cardiac transplantation. From a consecutive series of 91 cases]. / Analyse des causes d'échec après transplantation cardiaque. D'après une série consécutive de 91 cas.

Ninety-three cardiac transplantations were carried out in 91 patients (2 retransplantations) between March 1st 1987 and November 1st 1989, in 84 adults and 7 children under 15 years of age. The indications were dilated cardiomyopathy (48%), ischemic cardiomyopathy (35%), decompensated valvular heart disease (11%), congenital heart disease (3%) and two cases of Uhl's anomaly. Twelve patients underwent transplantation after external circulatory assistance (13%), 11 patients after inscription on the list of extreme emergencies, and 68 on an elective basis (74%). The postoperative immunosuppressive protocol was triple therapy: Ciclosporine, Azathioprine and Prednisone. Three of the children died. The early adult mortality was 9 cases (10.7%). It was 8% in patients operated electively. Major infectious complications occurred in 10 patients (11%). Rejection was looked for by systematic endomyocardial biopsy and echocardiography. Three hundred and forty-nine biopsies were made. Thirty-five patients (44%) had no problems of rejection. Seventy-nine patients have now been followed up for an average of 19 months. There were 7 late deaths. Seventy seven per cent of the survivors are asymptomatic. Acute rejection and transplant dysfunction were the two main causes of early mortality after cardiac transplantation. Although the long-term prognosis is uncertain, the medium-term results are very encouraging.

[Assisted circulation by external heterotopic prosthesis as a bridge to heart transplantation]. / Assistance circulatoire en attente de transplantation cardiaque par prothèse hétérotopique externe.

Eleven patients aged 7 to 58 years were placed on assisted circulation with Pierce (2 cases) or Abiomed (9 cases) external prosthetic ventricles as a bridge to cardiac transplantation. The indications were terminal cardiac failure following cardiomyopathy (7 cases), decompensated ischemic heart disease (3 cases) and subacute post-transplantation rejection (1 case). The duration of the assisted circulation ranged from 24 hours to 11 days. All patients were transplanted but 3 died after transplantation (27%). The circulatory assistance was satisfactory in all patients as shown by the regression of clinical signs of low cardiac output and the normalisation of diuresis. The complications observed during assisted circulation and after cardiac transplantation were: haemorrhage (36%), infection (27%) and thromboembolism (9%). These preliminary results with a 72% post-transplantation survival rate, show that both systems are effective "bridges to cardiac transplantation". The Abiomen device is excellent value for money and relatively simple to install and represents a good compromise between the sophisticated techniques of circulatory assistance and the problems of the cost of health care.

Use of the Abiomed BVS System 5000 as a bridge to cardiac transplantation.

The Abiomed BVS System 5000 (Abiomed Cardiovascular, Inc., Danvers, Mass.) is a gravity-filled, pneumatically driven external prosthetic ventricle that has been implanted as a circulatory support device in six patients 9 to 58 years of age, presenting with a refractory heart failure nonamenable to any type of corrective operation. Three (including a 9-year-old girl) had an end-stage nonobstructive myocardiopathy, and two (including one patient who had had a massive recent myocardial infarction) had an ischemic heart disease. When first seen, the 58-year-old patient had an acute rejection and graft failure occurring 2 months after a first transplantation. All patients showed evidence of a low-output state (cardiac index less than 1.5 L/min/m2), with renal failure (mean urinary output, less than 27 ml/min) and hypoxia (mean arterial oxygen pressure = 56 torr under 80% forced inspiratory oxygen), despite maximum pharmacologic support (dobutamine, 16 to 18 gamma/kg/min; dopamine, 3 to 18 gamma/kg/min; adrenaline, 0.2 to 0.7 gamma/kg/min; furosemide, 7 to 17 gamma/kg/min). The device was implanted through a midline sternotomy and under peripheral normothermic bypass. Five patients received a biventricular support, and one a single left prosthetic ventricle. The cannulation included a right-angled cannula in both the left and right atrium and a suture of the arterial Dacron tubes onto the ascending aorta and main pulmonary artery. After careful deairing of the tubing and ventricles, the console was activated and the bypass progressively discontinued. Heparin infusion was begun 3 hours after chest closure and was continued for the duration of assist pumping, which was 2 to 11 days (mean duration, 7.43 days). The system could provide a complete support of the circulation with both right and left ventricular index remaining stable at 2.4 to 3 L/min/m2. After a dramatic improvement at the time of the system activation, the urinary output remained adequate, thus allowing for a decreasing need for diuretic therapy. In two cases, including one of isolated left ventricular assist pumping, the circulation could be totally supported during 11 hours and 23 hours, respectively, of refractory ventricular tachycardia. Four of six patients were shortly weaned from inotropic agents. Hematologic studies showed a moderate decrease of the coagulation factors level during the first 6 hours of circulatory support, and this remained stable and within normal limits thereafter. There have been three cases of bleeding complications necessitating surgical revision on the sixth hour, the twelfth hour, and the sixth day, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

[Treatment of ventriculo-pulmonary disconnections with prosthetic conduits. Long-term results]. / Traitement des discontinuités ventriculo-pulmonaires par utilisation d'un tube valvulé. Résultats à long terme.

Between 1973 and 1989, 81 consecutive patients aged 2 to 42 years old, with ventriculo-pulmonary discontinuity, were treated by implantation of prosthetic conduits. The initial pathology was Tetralogy of Fallot (33%), complete transposition of the great arteries (20%), truncus arteriosus (17%), double outlet right ventricle (17%) and atrioventricular discordance with L malposition of the great arteries (10%). The overall early mortality was 22% (18 cases) and 14% (5 cases) in the 36 patients operated after 1982. Sixty three patients were followed up for 3 months to 16 years; there were 8 late deaths which occurred spontaneously or at reoperation. Postoperative catheterisation was carried out in 33 cases; the average ventriculopulmonary systolic pressure gradient was 40 +/- 26 mmHg. Six patients were reoperated to change the conduit, on average 6 years +/- 23 months after the first operation. Five other patients underwent endoluminal dilatation of a stenosed conduit which delayed reoperation to change the conduit in 3 cases. Prosthetic conduits have been extensively used in patients with ventriculo-pulmonary discontinuity because they are readily available. However, because of progressive degradation of the prostheses between the 5th and 10th postoperative years, other therapeutic solutions should be considered, i.e. endoventricular repair when possible and, in other cases, the use of aortic homografts.