In a 2-yr period 12 infants less than 2 mo of age underwent surgery for critical coarctation of the aorta. All had severe congestive failure with unsatisfactory response to medical therapy. In all patients the coarctation was located in the preductal or preligamentous region. Eleven patients had an associated ventricular septal defect (VSD). Early (1-mo) survival in the patients with VSD was 82%. Two early deaths occurred; there have been five late deaths on follow-up of up to 30 mo. In all patients who expired, the cause of death was unrelated to the coarctation repair. Recurrent coarctation has occurred in one patient. Early aggressive surgical intervention is indicated in the management of coarctation of the aorta both with and without VSD.

Four pediatric patients with subclavian steal syndrome (SSS) are described. One patient with congenital SSS had persistence of the lesion following surgical repair of coarctation of the aorta due to a gradient across a hypoplastic aortic arch. In 3 patients SSS developed on an acquired basis as a sequel to corrective operation, for coarctation in 1 patient, and interrupted aortic arch in 2 patients. Contributory factors included hypoplasia of the aortic arch, anatomical variation of the origin of the vertebral artery, and discrete recoarctation involving the ostium of the subclavian artery. Treatment was by vertebral artery ligation in 3 patients and by prosthetic patch arterioplasty in the patient with recoarctation. The 4 patients remain asymptomatic on follow-up of 16 to 25 months.

Case histories of 2 patients with aortico-left ventricular tunnel are reported. A review of the literature on this subject shows a unique clinical profile. The electrocardiographic (ECG) and roentgenographic features as well as the hemodynamic and angiographic data of 18 previously reported patients are reviewed. The anatomy and pathophysiology of the defect are discussed and surgical management is described. It is recommended that surgical correction be carried out as soon as the diagnosis is established.

SUMMARY Expanding, adult‐length catheters to accommodate continuing somatic growth have been implanted in the course of shunts, either to the heart or peritoneum, in 12 hydrocephalic infants and young children. Three of four patients with direct cardiac shunts are doing well 22, 28 and 30 months following primary shunt operations, and five of eight patients with ventriculo‐peritoneal shunts are progressing favourably four to 10 months after shunt placement. While no claims can be made for long‐term benefits, the preliminary results of these procedures are encouraging. RÉSUMÉ Shunts ventriculaires allongés dans l'hydrocéphalie du nourrisson et de l'enfant Des catheters longs, de type adulte, ont été implantés chez 12 nourrissons et jeunes enfants hydrocéphales au cours de la première intervention de shunt. Le but était d'éviter la nécessité d'interventions répétées pour allonger le catheter en fonction de la croissance de l'enfant. Trois des quatre malades ayant eu un shunt cardiaque direct allaient bien 22, 28 et 30 mois plus tard; cinq des huit malades porteurs d'un shunt ventriculo‐péritonéal évoluaient favorablement quatre à dix mois après l'intervention. Aucune conclusion ne peut être tirée pour un bénefice à long terme mais les résultats préliminaires de ces precédés sont encourageants. ZUSAMMENFASSUNG Mitwachsende ventrikuläre Shuntsysteme bei Hydrocephalus im Säuglings‐ und Kindesalter Mitwachsende Katheter bis zur Erwachenenlänge sind bei 12 Säuglingen und Kleinkindern mit Hydrocephalus bei ihrer ersten Ventiloperation implantiert worden. Man wollte damit die Notwendigkeit wiederholter Operationen zur Katheterverlängerung während des Wachstums der Kinder vermeiden. Drei von vier Patienten mit direktem cardialen Shunt geht es 22, 28 und 30 Monate nach der Operation gut und fünf von acht Patienten mit ventriculo‐peritonealem Shunt machen vier bis zehn Monate nach der Operation gute Fortschritte. Da noch keine Aussagen über Langzeiterfolge gemacht werden können, sind doch die vorläufigen Ergebnisse dieses Vorgehens recht ermutigend. RESUMEN Derivaciones ventriculares expansivas para hidrocefalias en lactantes y niños Se han implantado catéteres expansivos, de tamaño de adulto, en 12 lactantes y niños pequeños hidrocefálicos durante su primera operación derivativa. El propósito era evitar la necesidad de operaciones repetidas para alargar los catéteres a medida que el niños crecía. Tres de cuatro pacientes con derivaciones cardíacas directas siguen bien, 22, 28 y 30 meses más tarde, y cinco de ocho pacientes con derivatión ventrículo‐peritoneal van progresando favorablemente a los cuatro‐diez meses después de la operacion. Aunque no puede pronunciarse sobre un beneficio a largo plazo, los resultados preliminares de estos procedimientos son alentadores.

The authors describe a technique for direct cardiac shunting in which an adult-size ventriculoatrial catheter is coiled in an intrathoracic Silastic pouch and implanted in infants with hydrocephalus. In three patients so treated, serial chest films have shown progressive uncoiling of the catheter over a follow-up interval of 6 to 14 months.

The morbidity and mortality of cystic fibrosis are consequences of chronic endobronchial obstruction. To retard or reverse the pulmonary complications, we have evaluated bronchoscopy and bronchial lavage with acetylcysteine∗∗Mucomyst, Mead Johnson Laboratories, Evansville, Ind. in the management of these children. Two groups have been treated: (1) a stable group in whom treatments were elective, and (2) those critically ill with advanced pulmonary insufficiency treated on an emergency basis. Our experience with 270 procedures in 100 patients forms the basis of this report.

A 9-year-old female presented with mitral regurgitation, heart failure, fever, abnormal serum proteins, elevated sedimentation rate, and elevated antihyaluronidase titer. At first thought to have rheumatic fever, she initially responded favorably to medical therapy which included corticosteroids. Evidence of progressive disease led to cardiac catheterization and angiography which demonstrated a left atrial myxoma which was successfully excised. Review of the literature reveals that 23 children with left atrial myxomas have been reported. These may present with embolic, obstructive, or constitutional symptoms. Most children have clinical evidence of mitral regurgitation. Associated heart failure, anemia, elevated sedimentation rate, elevated antihyaluronidase titer and initial favorable response to medical therapy often lead to the incorrect diagnosis of acute or chronic rheumatic heart disease. In these patients, increased endogenous hyaluronic acid excretion from tumor cells may lead to increased hyaluronidase and antihyaluronidase activity, abnormal serum proteins and elevated sedimentation rate.

Review of a large group of patients treated for spontaneous pneumothorax has revealed a progressively higher incidence of recurrence in the three periods studied, covering a span of seventeen years. During this time the immediate management of this entity has changed from simple bedrest plus occasional thoracentesis to the routine use of closed thoracostomy with water-seal suction drainage. Definite indications for operation have become established and include the following: (1) failure of prompt and complete re-expansion after closed thoracostomy; (2) one or more ipsilateral recurrences; (3) single recurrence with bilateral apical blebs; (4) simultaneous bilateral pneumothorax; (5) asynchronous bilateral pneumothorax; (6) single episode with apical lung cyst; (7) continued intrapleural bleeding.

Ebstein's disease in a severely cyanotic 7-year-old boy was successfully treated by anastomosing the superior vena cava to the right pulmonary artery. A discussion of impaired right heart function in Ebstein's disease is presented emphasizing the inefficiency of right atrial contraction as a consequence of the "atrialization" of the right ventricle. It is our belief that right heart bypass with a superior vena cava to right pulmonary artery anastomosis is the surgical procedure of choice in patients severely ill from Ebstein's disease.