Round ligament varices: sonographic appearance in pregnancy.

Round ligament varices (RLV) are an important clinical entity as they may cause hernia-like symptoms in the absence of a true hernia. When this condition is diagnosed correctly, unnecessary intervention may be prevented. We aimed to determine the significance and anatomy of RLV in pregnancy and to review and describe their clinical and sonographic appearance. We followed prospectively five patients who presented during pregnancy with clinical symptoms suspicious of an inguinal hernia. All patients were diagnosed with RLV on ultrasound examination. All patients were managed conservatively and in all five cases, RLV resolved spontaneously postpartum. The diagnosis of RLV should be considered in pregnant women presenting with a groin mass. Sonography is diagnostic and can save unnecessary surgical exploration and associated morbidity.

Cost-effectiveness of coarctation repair strategies: endovascular stenting versus surgery.

The cost-effectiveness of stent (ST) implantation for the repair of coarctation of the aorta (CoA) is not documented in the medical literature. Inflation-adjusted hospital costs for ST implantation and for surgical (SU) repair were obtained using the HBOC Cost Accounting System software and evaluated for all patients 5 years of age or older who underwent elective treatment of CoA between July 1997 and June 2001. The average age of the ST group (n = 10) to 9.5 +/- 3.5 years for the SU group (n = 12) (p > 0.10). The ST group had one failure due to inability to cross the CoA (failure rate, 10%). Successful repair was accomplished in all other ST cases and in all SU cases, with no residual systolic gradients at 1-year follow-up. Hospital length of stay for the ST group was 0.8 +/- 1.2 days compared to 3.5 +/- 0.5 days for the SU group (p < 0.001). The mean inflation-adjusted cost for the ST group was dollar 7,148 +/- 2,984 versus dollar 11,769 +/- 3,702 for the SU group (p < 0.005). By intention to treat analysis, the cost of repair in the ST-first group was dollar 8,325 +/- 3,354 given the 10% failure rate (p < 0.04 vs the SU only group). Sensitivity analysis demonstrates that cost of repair is lower with the ST-first strategy compared to SU only until the failure rate of ST implantation exceeds 39%. Repair of CoA using an endovascular stent strategy is cost-effective compared to conventional surgical repair.

A simple device for measuring the resolution of videoscopic cameras and laparoscopes in the operating room.

BACKGROUND: There is a need for a device that can be used to objectively evaluate the image quality provided by laparoscopic camera units in the operating room. METHODS: The device that we developed consists of a regular 10-mm or 5-mm laparoscopic port with a rectangular test unit built at the end. A standard test pattern slide with resolution bars is used for measurements. Using this assembly, a single-chip laparoscopic camera was compared with a three-chip laparoscopic camera at different wiring formats and camera settings by measuring the resolution on the monitor screen. RESULTS: Vertical resolution was found to be constant at 550 lines, regardless of the type of camera and wiring used. Of the three wiring formats, composite wiring provided the poorest image with both cameras. When enhancement was off, the horizontal resolution obtained with Y/C or RGB wiring was the same for the one-chip camera at 640 lines of horizontal resolution, whereas RGB cabling provided the best image for the three-chip camera at 800 lines. CONCLUSION: Using basic broadcasting principles, we have developed a simple device that is useful for the comparison of different camera, cabling, and laparoscope configurations in the operating room. This information can be used as objective criteria to judge the image quality in laparoscopic video- systems.

Cellular and molecular aspects of myocardial dysfunction.

Disruption of any one of a large number of balanced systems that maintain cardiomyocyte structure and function can cause myocardial dysfunction. Such disruption can occur either in response to acute stresses such as cardiac surgery with cardiopulmonary bypass and cross-clamping of the aorta or because of more chronic stresses resulting from factors such as genetic abnormalities, infection, or chronic ischemia. Several currently available therapies such as beta-adrenergic receptor agonists and antagonists, phosphodiesterase inhibitors, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and other agents affect cardiomyocytes in ways that are more far reaching than initially appreciated when these agents were first introduced into clinical practice. As our knowledge and understanding of myocardial dysfunction increases, particularly in the neonatal and pediatric patient, we will be able to further target interventions to highly specific perturbations of cellular function and individual genetic variability.

Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures.

BACKGROUND: The use of the Veress needle in laparoscopy to create the pneumoperitoneum has inherent risks; it may cause vascular and visceral injuries. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming. One alternative is to enter the abdomen using an optical trocar under direct view. Our aim was to determine whether the optical access trocar can be used to effect a safe and rapid entry in various laparoscopic procedures. METHODS: Over a 4-year period, the Optiview trocar was used for initial entry in 650 laparoscopic procedures. The procedures included cholecystectomy (n = 282), transabdominal inguinal hernia repair (n = 76), radiofrequency ablation of liver tumors (n = 73), adrenalectomy (n = 54), appendectomy (n = 41), colorectal surgery (n = 39), and various other procedures (n = 85). The following parameters were analyzed: presence of previous abdominal operations, site and duration of entry, and complications. RESULTS: Of the 650 patients, 156 (24%) had had previous abdominal operations. In 25 cases, previous trocar sites were reused for optical access. The optical trocar was inserted at the umbilicus in 495 patients (76%), in the right upper quadrant in 77 (12%), in the left upper quadrant in 26 (4%), in the upper midline in eight (1%), in the right lower quadrant in six (0.9%), and in the left lower quadrant in three (0.5%). In 35 patients undergoing posterior adrenalectomy, optical trocars were used to enter Gerota's space. Mean (SD) entry times were 92 (45) sec at the umbilical site, 114 (30) sec at the back, and 77 (35) sec at the remaining sites. Complications (0.3%) included one injury to the bowel and one injury to the gallbladder; however, they were recognized and repaired immediately. CONCLUSIONS: To our knowledge, this report comprises the largest series in which the optical access trocar was used for laparoscopic surgery. This device provides the basis for a safe and fast technique for initial trocar placement: it also has the potential to reduce costs. Thanks to our favorable experience, the optical trocar method has become the standard technique for abdominal access in our laparoscopic practice since 1995.

Endothelin receptor blockade reduces ventricular dysfunction and injury after reoxygenation.

BACKGROUND: Reoxygenation of hypoxic myocardium during repair of congenital heart defects results in poor ventricular function and cellular injury. Endothelin-1 (ET-1), a potent vasoconstrictor that increases during hypoxia, may suppress myocardial function and activate leukocytes. The objective was to determine whether administration of an endothelin receptor antagonist could improve ventricular function and decrease cardiac injury after hypoxia and reoxygenation. METHODS: Fourteen piglets underwent 90 minutes of ventilator hypoxia, 1 hour of reoxygenation on cardiopulmonary bypass, and 2 hours of recovery (controls). Nine additional animals received an infusion of Bosentan, an ET(A/B) receptor antagonist, (5 mg/kg per hour) during hypoxia and reoxygenation. RESULTS: Right and left ventricular dP/dt in controls decreased to 78% and 52% of baseline, respectively, after recovery (p < 0.05). In contrast, Bosentan-treated animals had complete preservation of RV dP/dt and less depression of LV dP/dt. Bosentan reduced the hypoxia and reoxygenation-induced elevation of ET-1 and iNOS mRNA at the end of recovery (p < 0.05). Bosentan-treated animals had diminished myocardial myeloperoxidase activity and lipid peroxidation compared with controls (p < 0.05). Myocardial apoptotic index, elevated by hypoxia and reoxygenation, was lower in the Bosentan-treated animals (p < 0.05). CONCLUSIONS: Endothelin-1 receptor antagonism improved functional recovery and decreased leukocyte-mediated injury after reoxygenation. The reduction in cardiac cell death might also improve long-term outcome after reoxygenation injury.

Unrecognized pulmonary venous desaturation early after Norwood palliation confounds Gp:Gs assessment and compromises oxygen delivery.

BACKGROUND: Hemodynamic stability after Norwood palliation often requires manipulation of pulmonary vascular resistance to alter the pulmonary-to-systemic blood flow ratio (Qp:Qs). Qp:Qs is often estimated from arterial saturation (SaO2), a practice based on 2 untested assumptions: constant systemic arteriovenous O2 difference and normal pulmonary venous saturation. METHODS AND RESULTS: In 12 patients early (

A critical analysis of intraoperative time utilization in laparoscopic cholecystectomy.

BACKGROUND: Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operation room; however, heretofore there has been no critical analysis of the time required to perform the various steps of the operation. An understanding of how operative time is used is the first step toward improving the efficiency of the procedure and decreasing costs while maintaining an acceptable standard of care. METHODS: Of 194 patients undergoing LC at a university hospital between 1994 and 1997, operational videotapes of 48 randomly chosen patients were reviewed. Three groups of patients were identified: those undergoing LC for chronic cholecystitis (n = 27), those undergoing LC for acute cholecystitis (n = 11), and those with common bile duct stones (CBDS), (n = 10) undergoing LC with transcystic common bile duct exploration. The procedure was divided into the following seven steps; trocar entry, laparoscopic ultrasound, dissection of the triangle of Calot, cholangiogram, dissection of the gallbladder, extraction of the gallbladder, and irrigation-aspiration with removal of ports. Time spent for camera cleaning, bleeding control, and insertion of the cholangiocatheter into the cystic duct was also calculated. The groups were compared in terms of time spent for each step using the Kruskal-Wallis and Mann-Whitney U tests. RESULTS: The mean +/- SD operating time was 66.5 +/- 20.5 min. The acute group had the longest operating time, followed by the CBDS and chronic groups. Dissection of the gallbladder, insertion of the cholangiocatheter, and irrigation-aspiration were longer steps in the acute group than in the other groups (p < 0.05). Dissection of the triangle of Calot took longer in acute cholecystitis than in chronic cholecystitis (p < 0.05). CBDS cases took longer (p < 0.05) than chronic cases because stone extraction added an average of 17.5 min to the time required for the cholangiogram in chronic cholecystitis. Laparoscopic ultrasound took longer in the CBDS group than in the other groups (p < 0.05). The mean +/- SD time spent for the cholangiogram and laparoscopic ultrasound in chronic cholecystitis was 7.5 +/- 4.3 and 4.8 +/- 1.9 min, respectively. CONCLUSIONS: This time analysis study demonstrates that acute cholecystitis requires a longer operating time because most of the individual steps in the procedure take longer. In patients with choledocholithiasis, stone extraction was responsible for longer operating times. This study should serve as a basis for future studies focusing on time utilization in laparoscopic surgery.

Hyperoxia for management of acid-base status during deep hypothermia with circulatory arrest.

BACKGROUND: Which blood gas strategy to use during deep hypothermic circulatory arrest has not been resolved because of conflicting data regarding the advantage of pH-stat versus alpha-stat. Oxygen pressure field theory suggests that hyperoxia just before deep hypothermic circulatory arrest takes advantage of increased oxygen solubility and reduced oxygen consumption to load tissues with excess oxygen. The objective of this study was to determine whether prevention of tissue hypoxia with this strategy could attenuate ischemic and reperfusion injury. METHODS: Infants who had deep hypothermic circulatory arrest (n = 37) were compared retrospectively. Treatments were alpha-stat and normoxia (group I), alpha-stat and hyperoxia (group II), pH-stat and normoxia (group III), and pH-stat and hyperoxia (group IV). RESULTS: Both hyperoxia groups had less acidosis after deep hypothermic circulatory arrest than normoxia groups. Group IV had less acid generation during circulatory arrest and less base excess after arrest than groups I, II, or III (p < 0.05). Group IV produced only 25% as much acid during deep hypothermic circulatory arrest as the next closest group (group II). CONCLUSIONS: Hyperoxia before deep hypothermic circulatory arrest with alpha-stat or pH-stat strategy demonstrated advantages over normoxia. Furthermore, pH-stat strategy using hyperoxia provided superior venous blood gas values over any of the other groups after circulatory arrest.

Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors.

BACKGROUND: Accurate staging of malignant tumors in the liver has major implications in defining prognosis and guiding both surgical and nonsurgical therapy. Intraoperative ultrasound in open surgery compares favorably with computed tomography (CT) in the detection of liver tumors; however, there is little experience with laparoscopic ultrasound (LUS). HYPOTHESIS: Laparoscopic ultrasound is more sensitive than triphasic CT for detecting primary and metastatic liver tumors. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Fifty-five patients with a total of 222 lesions, including primary and metastatic liver tumors, who underwent both CT examinations and LUS as a part of a tumor ablation procedure. INTERVENTIONS: Triphasic spiral CT scans of the liver were obtained within 1 week before surgery. Liver LUS was performed with a linear 7.5-MHz side-viewing laparoscopic transducer. RESULTS: The LUS detected all 201 tumors seen on preoperative CT and detected 21 additional tumors (9.5%) in 11 patients (20.0%). These tumors missed by CT ranged in size from 0.3 to 2.7 cm. Smaller tumors tended to be missed by CT scan (28.6% of the lesions <1 cm, 15.8% of those 1-2 cm, 4% of those 2-3 cm, and 0% of those >3 cm), as did those in segments III and IV. There was good correlation between the size of lesions imaged by the 2 modalities (Pearson r = 0.86; P<.001). CONCLUSION: Laparoscopic ultrasound offers increased sensitivity over CT for the detection of liver tumors, especially for smaller lesions. This study documents the ability of LUS in detecting liver tumors and argues for more widespread use in laparoscopic staging procedures.

Acute hypoxia and reoxygenation impairs exhaled nitric oxide release and pulmonary mechanics.

OBJECTIVE: Changes in exhaled nitric oxide levels often accompany conditions associated with elevated pulmonary vascular resistance and altered lung mechanics. However, it is unclear whether changes in exhaled nitric oxide reflect altered vascular or bronchial nitric oxide production. This study determined the effects of acute hypoxia and reoxygenation on pulmonary mechanics, plasma nitrite levels, and exhaled nitric oxide production. METHODS: Ten piglets underwent 90 minutes of hypoxia (fraction of inspired oxygen = 12%), 1 hour of reoxygenation on cardiopulmonary bypass, and 2 hours of recovery. Five additional animals underwent bypass without hypoxia. Exhaled nitric oxide, plasma nitrite levels, and pulmonary mechanics were measured. RESULTS: Exhaled nitric oxide decreased to 36% of baseline by end hypoxia (34 +/- 14 vs 12 +/- 9 ppb, P =.005) and declined further to 20% of baseline at end recovery (7 +/- 6 ppb). Aortic nitrite levels decreased from baseline during hypoxia (from 102 +/- 13 to 49 +/- 7 micromol/L, P =.05) but returned to baseline during recovery. Pulmonary arterial nitrite also decreased during hypoxia (from 31.4 +/- 7.8 to 22.9 +/- 9.5 micromol/L, P =.04) and returned to baseline at end recovery. Decreased production of exhaled nitric oxide was associated with impaired gas exchange (alveolar-arterial gradient = 32 mm Hg at baseline and 84 mm Hg at end recovery), decreased pulmonary compliance (6.6 +/- 0.9 mL/cm H(2)O at baseline, 5.0 +/- 0.7 mL/cm H(2)O at end hypoxia, and 5.4 +/- 0.7 mL/cm H(2)O at end recovery), and increased inspiratory airway resistance (41 +/- 4 cm H(2)O. L(-1). s(-1) at baseline, 56 +/- 4.9 cm H(2)O. L(-1). s(-1) at end hypoxia, and 50 +/- 5 cm H(2)O. L(-1). s(-1) at end recovery). CONCLUSIONS: A decrease in exhaled nitric oxide persisted after hypoxia, and plasma nitrite levels returned to baseline on reoxygenation, indicating that alterations in exhaled nitric oxide during hypoxia-reoxygenation might be unrelated to plasma nitrite levels. Furthermore, decreased exhaled nitric oxide corresponded with altered pulmonary mechanics and gas exchange. Reduced exhaled nitric oxide after hypoxia-reoxygenation might reflect bronchial epithelial dysfunction associated with acute lung injury.

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis.

HYPOTHESIS: Tube cholecystostomy followed by interval laparoscopic cholecystectomy is a sale and efficacious treatment option in critically ill patients with acute cholecystitis. DESIGN: Retrospective cohort study within a 4 1/2%-year period. SETTING: University hospital. PATIENTS: Of 324 patients who underwent laparoscopic cholecystectomy, 65 (20%) had acute cholecystitis; 15 of these 65 patients (mean age, 75 years) underwent tube cholecystostomy. INTERVENTION: Thirteen patients at high risk for general anesthesia because of underlying medical conditions underwent percutaneous tube cholecystostomy with local anesthesia. Laparoscopic tube cholecystostomy was performed on 2 patients during attempted laparoscopic cholecystectomy because of severe inflammation. Interval laparoscopic cholecystectomy was attempted after an average of 12 weeks. MAIN OUTCOME MEASURES: Technical details and clinical outcome. RESULTS: Prompt clinical response was observed in 13 (87%) of the patients after tube cholecystostomy. Twelve patients (80%) underwent interval cholecystectomy. Laparoscopic cholecystectomy was attempted in 11 patients and was successful in 10 (91%), with 1 conversion to open cholecystectomy. One patient had interval open cholecystectomy during definitive operation for esophageal cancer and another had emergency open cholecystectomy due to tube dislodgment. Two patients (13%) had complications related to tube cholecystostomy and 2 patients died from sepsis before interval operation. One patient died from sepsis after combined esophagectomy and cholecystectomy. Postoperative minor complications developed in 2 patients. At a mean follow-up of 16.7 months (range, 0.5-53 months), all patients were free of biliary symptoms. CONCLUSIONS: Tube cholecystostomy allowed for resolution of sepsis and delay of definitive surgery in selected patients. Interval laparoscopic cholecystectomy was safely performed once sepsis and acute infection had resolved in this patient group at high risk for general anesthesia and conversion to open cholecystectomy. Just as catheter drainage of acute infection with interval appendectomy is accepted in patients with periappendiceal abscess, tube cholecystostomy with interval laparoscopic cholecystectomy should have a role in the management of selected patients with acute cholecystitis.

Tesio catheter: radiologically guided placement, mechanical performance, and adequacy of delivered dialysis.

PURPOSE: Tunneled catheters are an alternative means of vascular access for patients in need of hemodialysis who cannot undergo dialysis through a surgical shunt. This study was undertaken to evaluate the performance of the Tesio dialysis catheter. MATERIALS AND METHODS: A prospective study of the Tesio catheter was performed. Follow-up data regarding catheter function and adequacy of dialysis were obtained from nine hemodialysis facilities. RESULTS: Seventy-nine Tesio catheters were placed in 71 patients. Immediate technical success was 99% (78 of 79 catheters). The procedure complication rate was 9% (seven catheters). Only two complications required intervention: one fatal air embolism and one chest wall hematoma. Sixty-seven catheters in 60 patients were followed up for a total of 4,367 catheter days. Overall, catheter-related infection occurred in 9% (six of 67 catheters). Primary catheter patency was 87% at 1 week, 82% at 1 month, 72% at 3 months, and 66% at 6 months. Mean blood flow was 286 mL/min immediately after insertion, 301 mL/min at 3 months, and 306 mL/min at 6 months. Adequate dialysis dose as reflected by a urea reduction ratio of 60 or more or a urea kinetic modeling, or Kt/V, value of 1.2 or more was observed on at least one occasion for 74% and 76% of catheters, respectively. CONCLUSION: The Tesio catheter is a reasonable means of vascular access for patients who undergo dialysis but are not candidates for surgical shunt placement.

Bosentan prevents hypoxia-reoxygenation-induced pulmonary hypertension and improves pulmonary function.

BACKGROUND: Acute hypoxia results in increased pulmonary vascular resistance. Despite reoxygenation, pulmonary vascular resistance remains elevated and pulmonary function is altered. Endothelin-1 might contribute to hypoxia-reoxygenation-induced pulmonary hypertension and to reoxygenation injury by stimulating leukocytes. This study was carried out using an established model of hypoxia and reoxygenation to determine whether endothelin-1 blockade with Bosentan could prevent hypoxia-reoxygenation-induced pulmonary hypertension and reoxygenation injury. METHODS: Twenty neonatal piglets underwent 90 minutes of hypoxia, 60 minutes of reoxygenation on cardiopulmonary bypass, and 2 hours of recovery. Control animals (n = 12) received no drug treatment, whereas the treatment group (n = 8) received the endothelin-1 receptor antagonist, Bosentan, throughout hypoxia. RESULTS: In controls, pulmonary vascular resistance increased during hypoxia to 491% of baseline and remained elevated after reoxygenation; however in the Bosentan group, it increased to only 160% of baseline by end-hypoxia, then decreased to 76% at end-recovery. Arterial endothelin-1 levels in controls increased to 591% of baseline after reoxygenation. Arterial nitrite levels decreased during hypoxia in controls but were maintained in the Bosentan group. Consequently, animals in the Bosentan group had better postreoxygenation pulmonary vascular resistance, A-a gradient, and airway resistance along with lower myeloperoxidase levels than controls. CONCLUSIONS: Acute hypoxia and postreoxygenation pulmonary hypertension was attenuated by Bosentan, which maintained nitric oxide levels during hypoxia, decreased leukocyte-mediated injury, and improved pulmonary function.

Effect of modified ultrafiltration on plasma thromboxane B2, leukotriene B4, and endothelin-1 in infants undergoing cardiopulmonary bypass.

BACKGROUND: Plasma thromboxane B2 (TXB2), leukotriene B4 (LTB4), and endothelin-1 (ET-1) levels increase on cardiopulmonary bypass (CPB). Elevated levels of TXB2 and ET-1 have been correlated with postoperative pulmonary hypertension in infants undergoing repair of congenital heart defects. LTB4 is a potent chemotactic cytokine whose levels correlate with leukocyte-mediated injury. Modified ultrafiltration (MUF) has been associated with improved hemodynamics and pulmonary function, in addition to its beneficial effects on fluid balance and blood conservation. Recent investigations have suggested that removal of cytokines may be the cause of the improved cardiopulmonary function seen with MUF. METHODS: Plasma TXB2, ET-1, and LTB4 levels were measured in 34 infants undergoing CPB: 22 underwent MUF (group 1), and 12 did not (group 2). Samples were obtained at various time points. All patients underwent conventional ultrafiltration during the rewarming phase of cardiopulmonary bypass. RESULTS: In group 1, mean end-CPB TXB2 level was 101.2 pg/mL versus 46.9 pg/mL post-MUF (p < 0.05). The mean TXB2 level 1 hour post-CPB (54.1 pg/mL) was not significantly different from the post-MUF level. In group 2, the mean end-CPB TXB2 level was 123.6 pg/mL versus 53.2 pg/mL 1 hour post-CPB. Hence, TXB2 levels decreased by similar amounts and to similar levels by 1 hour post-CPB in both groups. ET-1 levels increased after CPB and were unaffected by MUF: 1.45, 1.80, 2.55 pg/mL at end-CPB, post-MUF, and 1 hour post-CPB, respectively, in group 1; and 1.51, and 2.73 pg/mL at end-CPB and 1 hour post-CPB in group 2. LTB4 levels post-MUF were 119% of pre-MUF values, and were similar at 1 hour post-CPB in both groups. CONCLUSIONS: Despite reduction in TXB2 by MUF, values were similar and approached baseline 1 hour post-CPB in both groups. LTB4 levels increased slightly with MUF. ET-1 levels increased during and post-CPB and were unaffected by MUF. MUF does not appear to have a significant effect on post-CPB levels of TXB2, ET-1, and LTB4. Therefore, the improved hemodynamics observed with MUF do not appear to be related to removal of these cytokines.

Primum atrial septal defect.

UNLABELLED: The purpose of this report is to review our surgical experience with primum atrial septal defect. Since 1982, infants with primum atrial septal defect have undergone complete repair consisting of closure of the cleft of the left atrioventricular valve and atrial septal defect with a pericardial patch. Ages at operation ranged from early neonatal period until 5 years. In most patients, echocardiography was diagnostic and cardiac catheterization was performed in children with associated defects. Severe congestive heart failure and left atrioventricular valve regurgitation necessitated earlier correction. Infants with coarctation of the aorta and primum atrial septal defect underwent a two-stage procedure involving coarctation resection followed by complete repair. The early mortality rate is less than 1% and has a reoperation rate of less than 3%. The overall long-term survival of patients with primum atrial septal defect matches that of the general population. CONCLUSION: The diagnosis of primum atrial septal defect can easily be made by echocardiography with cardiac catheterization reserved for patients with associated left-sided obstruction. For patients in stable condition, the total repair can be performed before 2 to 3 years of age with minimum mortality. In infants with severe congestive heart failure, earlier correction should be contemplated, although it carries a higher morbidity. The associated coarctation of aorta is infrequent, but requires resection before intracardiac repair. The long-term results with this lesion repair are excellent.