COgnitive enhancement and consumption of psychoactive Substances among Youth Students (COSYS): a cross-sectional study in France.

OBJECTIVES: This descriptive and analytical study investigated the consumption rates of psychoactive substances among individuals aged 18-25 years in France. More specifically, it enabled assessment of the extent of the neuroenhancement (NE) phenomenon among students in France (including study of the misuse of psychostimulant medicines). STUDY DESIGN: COgnitive enhancement and consumption of psychoactive Substances among Youth Students (COSYS) is a cross-sectional survey of students in France. METHODS: Between January and June 2017, a questionnaire was mailed to students. All questionnaires were completed anonymously and included questions regarding the use of all kind of psychoactive substances, motivations for use and socio-economic situations. Statistics for all variables and the results of a multiple correspondence analysis (MCA) are presented. RESULTS: This study recorded 46,203 respondents, mostly in universities (>60%), mostly women (63.4%), with an average age of 21.4 years. In terms of substance use, medications were cited in the third position after alcohol and tobacco by women (22.48%) and in the fourth position after alcohol, tobacco and cannabis by men (15.14%). Among medications, opiates were the most frequently used, followed by benzodiazepines. Students who declared a non-medical use (NMU) of drugs obtained these through various ways (e.g. family medicine cabinet, a friend, a dealer or via the Internet), or by increasing their recommended doses (e.g. codeine). In total, 18.6% of students consumed psychoactive substances for 'stress management' and 14.1% for 'sleep management'. Results indicated that NE in students is a problem, with 18.6% of students in the COSYS survey confirming the use of psychoactive substances for this reason. There was a very low prevalence for psychostimulant medications (0.57% of men), mostly NMU (67%). MCA yielded three different profiles (doping candidate, experimenter and psychiatric profile) of psychostimulant users, which complicates the implementation of prevention programmes. CONCLUSIONS: It is evident that NMU and 'conventional' use of medications are highly prevalent in French students, especially females. NMU is associated with substance use disorders, psychopathology and suicidality. Social norms and social media increase NMU of psychoactive substances, but also provide a potential platform for anti-NMU campaigns. CLINICAL TRIAL REGISTRATION NUMBER: NCT02954679.

[Cathinones use in Paris]. / Usage de cathinones à Paris.

BACKGROUND: The pattern of recreational drug use has changed over the last decade and now includes a multitude of substances sold as "research chemicals" or new psychoactive substances, "NPS". In France, synthetic cathinones emerged in 2008 (while first mentioned by the French police force in 2007 first alerts among users appeared in 2008) and have grown to be popular drugs of abuse. Under the Official Journal dated 11th June 2010, only mephedrone has been listed as narcotics but "designer drugs" have synthesized new substitute cathinones in order to avoid anti-drug laws. However, since July 2012, in France, all synthetic drugs from the cathinones family have been banned and listed as narcotics following the example of United Kingdom. Despite their recent classification and inclusion on narcotic list, they are readily available on Internet and used widely. Paris Addictovigilance Centre observed a signal of derivate cathinones abuse (21 cases over a two-year period). OBJECTIVE: Paris Addictovigilance Centre and Marmottan Hospital wanted to describe the use of cathinones in the Paris area and alert the health care community about the abuse identification and risk assessment problems of these compounds. After a review of derivated cathinone's chemical structure, pharmacology and toxicology, this article seeks to provide patricians with a clinical description and treatment's modality. RESULTS: Most users of synthetic cathinones will experience euphoria, increased energy, talkativeness, openness and increased sexual arousal. Signs and symptoms of toxicity are consistent with a sympathomimetic toxidrome. The main reasons for care access are psychiatric (hallucinations, psychotic symptoms, agitation) and addiction disorders. Somatic complications were described with various patterns of symptoms such as headache, tachycardia, confusional states, rhabdomyolysis with renal failure or serotonin syndrome. The most important fact is the apparition of the "slam" phenomenon among men who have sex with men (MSM). The "slam" is a compound of three characteristic elements: injection, sexual party and psychostimulant drug. According to users, "slam" is convenient for group sex and is used it to put them into a good mood and a disinhibition state. These compounds cause fast dependence syndrome with strong craving and prolonged psychiatric symptoms and increase infectious risk (HIV, VHC, VHB…). The cathinones family is not detected in conventional urine drug screenings. We point out the lack of confirmatory analytic testing data which remains the only way to determine the actual etiology of the clinical effects observed since drug users do not always know exactly what they took. These substances can be identified by special analyses using gas chromatography or liquid chromatography and mass spectroscopy technology. CONCLUSION: This injection drug is used in order to increase sexual desire, delay orgasm and decrease sexual inhibition and is prevalent in many studies on MSM samples. Cathinones would popularize the "slam". Harm reduction policy requires specific MSM interventions on both sexual and drug addiction networks.

[Acute and chronic toxicities associated with the use and misuse of nitrous oxide: An update]. / Toxicités aiguës et chroniques associées à l'usage et au mésusage du protoxyde d'azote : mise au point.

Nitrous oxide (N2O) is used since the eighteenth century as an anesthetic and analgesic but also for recreational use. If the labelled uses of N2O and their modalities are nowadays perfectly framed, the misuse of N2O takes very alarming proportions among teenagers and young adults. This misuse is the cause of acute (hypoxia, barotrauma, burns, neuropsychiatric disorders) and chronic complications if repeated (myeloneuropathy, anemia, thrombosis, inhalant use disorder). The main mechanism of the latter is mainly related to a functional deficit in vitamin B12 induced by N2O. The management of acute complications is symptomatic. The management of chronic complications is based on vitamin B12 supplementation. The best biomarker of chronic N2O exposure is the elevation of the plasmatic level of methylmalonic acid. In all cases of recreational misuses, addiction treatment is necessary to prevent complications or their worsening by providing information in order to stop consumption.

Voriconazole pharmacokinetic variability in cystic fibrosis lung transplant patients.

BACKGROUND: Aspergillosis is a high-risk complication in cystic fibrosis (CF) lung transplant patients. Azole antifungal drugs inhibit CYP3A4, resulting in significant metabolic drug-drug interactions. Voriconazole (VRZ) was marketed without therapeutic drug monitoring (TDM) recommendations, consistent with favorable pharmacokinetics, but regular determinations of plasma VRZ concentration were introduced in our center to manage interactions with calcineurin inhibitors and to document the achievement of therapeutic levels. METHODS: VRZ TDM data analysis for trough concentration (C0) and peak concentration (C2) was carried out, using validated liquid chromatography assay with ultraviolet detection, for 35 CF lung transplant patients (mean age 25 years, mean weight 47 kg, balanced sex ratio) since 2003. Therapeutic range (C0: 1.5 +/- 0.5 - C2 : 4.0 +/- 1.0 mg/L) was expressed relative to pivotal pharmacokinetic trial data. RESULTS: The duration of VRZ treatment ranged from 9 days to 22 months. The recommended standard dose of VRZ (200 mg twice a day, following the loading dose) resulted in significant plasma concentrations (>0.5 mg/L) in 20% of CF lung transplant patients. Therapeutic concentrations were obtained using higher doses (average 570 +/- 160 mg/day, +43%, P<0.01). Despite adaptation, C0 remained <0.5 mg/L (11%), even when the drug was administered intravenously, highlighting the variability of VRZ pharmacokinetics, possibly enhanced by CYP2C19 polymorphism. The risk of inefficacy during periods of underdosage was overcome by treatment with antifungal drug combinations (caspofungin, n=10). The therapeutic index was limited by neurologic effects (14%) and hepatic abnormalities (30%). VRZ concentrations correlated significantly (P<0.01) with aspartate aminotransferase levels but not with bilirubin levels. VRZ acted as a metabolic inhibitor of tacrolimus (C0 to dose ratio 5.8 +/- 2.6, n=31/VRZ versus 1.7 +/- 0.9 alone, P<0.001). Large changes in azole concentration affected the magnitude of the drug-drug interactions and adjustment requirements. CONCLUSIONS: TDM is required because VRZ levels are often undetectable in treated CF lung transplant patients, supporting the use of antifungal drug combinations until achievement of VRZ C0 at a steady state between 1 and 2 mg/L. Plasma VRZ concentrations should be determined for the quantitative, individualized management of drug-drug interactions in lung transplant patients, in particular immunosuppressant such as tacrolimus, considering VRZ to be both a target and an inhibitor of CYP3A4.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. I. Criteria of surgical decision.

The feasibility of anatomic repair (defined as the reconstruction of normal ventriculoarterial connection) was investigated in 104 patients who underwent an operation for anomalies of ventriculoarterial connection associated with ventricular septal defect. Three types of anatomic repair were used: intraventricular rerouting, REV (association of intraventricular rerouting with translocation of the pulmonary arterial trunk on the right ventricle), and arterial switch associated with closure of the ventricular septal defect. Intraventricular repair was considered to be the best and simplest method when possible. In the other cases, REV was indicated if pulmonary outflow tract obstruction was present, and arterial switch was performed when the tract was patent. The feasibility of intraventricular repair was related to the distances between the tricuspid valve and the semilunar valves. Preoperative measurement of these distances is an essential criterion to choose the appropriate repair of anomalies of ventriculoarterial connection associated with ventricular septal defect.

Video-assisted thoracoscopic surgical interruption: the technique of choice for patent ductus arteriosus. Routine experience in 230 pediatric cases.

Video-assisted thoracoscopic surgical interruption for patient ductus arteriosus is a well-standardized procedure already described. We present our entire series of such cases, from the first case (performed on Sept. 5, 1991) to March 1, 1995. Two hundred thirty patients in a variety of age groups underwent video-assisted interruption: younger than 6 months (70 patients, 30%), 6 to 48 months (123 patients, 54%), and older than 48 months (37 patients, 16%). The mean weight was 12.6 kg (range 1.2 to 65 kg). Thirty-nine patients had symptomatic pulmonary hypertension. Associated intracardiac anomalies included atrial septal defect (three), ventricular septal defect (five), and anomalous pulmonary venous return (one). All patients underwent video-assisted interruption of the patient ductus arteriosus with two titanium clips. Closure was evaluated by postoperative echocardiography before extubation. Five patients had a persistent patent ductus after video-assisted interruption, all early in our experience and related to insufficient dissection resulting in inadequate clip placement. Four patients had successful immediate clip repositioning (three by video-assisted interruption and one by thoracotomy). Subsequent echocardiography revealed persistent closure in these patients. A persistent patent ductus arteriosus with minimal flow was discovered in one patient without symptoms after discharge. Recurrent laryngeal nerve dysfunction was noted in six patients (2.6%, five transient and one persistent). There were no deaths, hemorrhages, transfusions required, or chylothoraces in this series. Mean operative time was 20 +/- 15 minutes, and hospital stay averaged 48 hours for patients younger than 6 months and 72 hours for patients older than 6 months. This is a safe, rapid, cost-effective technique that results in excellent results and a shortened hospital stay. Video-assisted interruption represents the technique of choice for closure of a patient ductus arteriosus.

A new video-assisted thoracoscopic surgical technique for interruption of patient ductus arteriosus in infants and children.

Classic surgical interruption of patent ductus arteriosus was partially replaced by transcatheter endovascular closure in 1971. We describe a new technique for ductus closure by video-assisted thoracoscopic surgical interruption, derived from video-assisted endoscopic surgery. With the patient under general anesthesia and intubated, two 5 mm holes were made through the left thoracic wall. A video camera and specially devised surgical tools were introduced; such as scissors, dissectors, and clip appliers. The ductus was dissected, and two titanium clips were applied, completely interrupting the ductus. Thirty-eight patients were operated on from April 1991 to April 1992. Mean age was 23.3 months (range 1.5 to 90 months) and mean weight was 9.5 kg (range 2.4 to 25 kg). Six had associated lesions not necessitating immediate surgical treatment. All had successful closure of the patent ductus with the video-assisted technique, but two needed two such procedures, one because of incomplete immediate ductus closure and one because of partial opening of the clip after 24 hours. One patient had recurrent laryngeal nerve injury and four had pneumothorax on the left side. The usual hospital stay was 2 or 3 days. There were no other complications and no deaths. Video-assisted thoracoscopic surgical interruption was a rapid, safe, and successful technique for closure of the patent ductus arteriosus. Better dissection of the ductus decreased the risk of recurrent laryngeal nerve injury and that of clip opening. In the last 26 patients, in whom a 2 mm multiperforated catheter was used for chest drainage during the first hours, no pneumothoraces occurred. Video-assisted thoracoscopic interruption of the patent ductus arteriosus is feasible in low-weight infants, whereas transcatheter endovascular closure of the ductus usually is not possible. The technique will be applied to premature infants with new instruments designed for the size of these patients.

Mediastinal infection after cardiac operation. A simple closed technique.

From March 1984 to March 1987, a simple closed method, previously described for the treatment of osteomyelitis after orthopedic operations, was used to treat deep sternal infection in 11 patients. The basis of this technique is, after meticulous débridement of the wound, to drain all the infected areas with small catheters connected to a bottle inside of which a strong (700 mm Hg) negative pressure is created (Redon drainage device). The method does not require irrigation. The maximum duration of the drainage was 24 days and complete recovery was obtained in all patients without further surgical treatments. The comfort of the patients was optimal.

Anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect. II. Clinical results in 50 patients with pulmonary outflow tract obstruction.

From November 1980 to November 1985, 50 patients underwent anatomic repair of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction. The technique used was one that we have previously described, which we call REV. The principles of this technique are resection of the infundibular septum, construction of a tunnel connecting the left ventricle to the aorta, and direct anastomosis, without a prosthetic conduit, of the pulmonary arterial trunk with the right ventricle. The tunnel is situated beneath the aortic valve and occupies very little space in the right ventricular cavity. Age at operation ranged from 4 months to 13 years (mean 3.5 years). Twenty-six patients had a classic type of transposition of the great arteries; all other patients had various types of anomalies of ventriculoarterial connection in which it was impossible, after the intraventricular connection of the left ventricle to the aorta, to use the natural pulmonary orifice for the pulmonary outflow tract reconstruction. There were nine hospital deaths (18%) and one late death. Twenty-six of 29 patients whose follow-up time exceeded 1 year had an excellent clinical result. No stenosis of the aortic outflow tract was found. Four patients had significant pressure gradients on the pulmonary outflow tract. Our present experience with REV suggests that this technique allows anatomic repair in a wide variety of anomalies of ventriculoarterial connection associated with ventricular septal defect and pulmonary outflow tract obstruction, even in infants, with an acceptable rate of mortality and morbidity.

Anatomic repair of anomalies of ventriculo-arterial connection (REV). Results of a new technique in cases associated with pulmonary outflow tract obstruction.

From November 1980 to November 1986, 63 patients aged 4 months to 13 years (mean 3.4 years) underwent repair of anomalies of ventriculo-arterial connection with ventricular septal defect and pulmonary outflow tract obstruction, using a technique (REV) first described by us in 1982. The selection of patients was based on preoperative criteria, namely the measurement of the distance between the tricuspid and the semilunar valves. These measurements enabled us to select from patients with an abnormal ventriculo-arterial connection, those in whom the anomaly could be repaired by intra-ventricular partition alone. In the remaining cases, REV was indicated in the presence of pulmonary stenosis. The principles of the technique are: (1) resection of the infundibular septum creating a large, direct and subarterial communication between the left ventricle and the aorta; (2) construction of a straight left ventricle to aorta tunnel by intraventricular partition; (3) direct anastomosis of the pulmonary trunk to the right ventricle. There were 12 hospital deaths (19%). The mean follow-up was 32 months. One patient died suddenly 1 year after repair. Six patients required reoperation. All survivors are in NYHA class I, except for 3 patients who are in class II. No stenosis of the left ventricular outflow tract was found but 5 patients had a significant pressure gradient at the pulmonary outflow tract level. Our present experience suggests that in properly selected patients, REV allows anatomic repair in a wide variety of anomalies of the ventriculo-arterial connection associated with VSD and pulmonary outflow tract obstruction with an acceptable rate of mortality and morbidity.

Video-thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases.

OBJECTIVE: Pediatric video-assisted thoracic surgery closure of patent ductus arteriosus can now be performed on a routine basis. We review here our entire experience with this technique. METHODS: Three hundred and thirty two consecutive patients underwent video-assisted closure of patent ductus arteriosus from September 1991 to September 1996. Indications were symptomatic ductus or failure of closure in older children. All complications were carefully noted, as well as intensive care unit stay, and operating room time. RESULTS: Patients were divided in three age groups: less than 6 months (101 patients, 31%), 6-48 months (179 patients, 54%), greater than 48 months (52 patients, 16%). The mean weight was 12.6 kg (range 1.2-65 kg). Associated cardiac anomalies were atrial septal defect (3), ventricular septal defect (5), anomalous pulmonary venous return (1). Six patients had a residual shunt following video-assisted interruption. Five patients had successful immediate clip repositioning (three via video-assisted interruption, two via thoracotomy). One patient continued to have a small shunt, which is followed medically. Complications included recurrent laryngeal nerve dysfunction in six patients (1.8%) (five transient, one persistent). Mean operating time was 20 +/- 1.5 mn and hospital stay averaged 48 h (> 6 months), 72 h (< 6 months). CONCLUSIONS: Interruption of patent ductus can be safely performed by video-assisted technique with minimal morbidity and no mortality. It can be performed in all age group with minimal hospital stay.

Video surgical technique for interruption of patent ductus arteriosus in children and neonates.

Classical surgical interruption of PDA has partially been replaced by trans catheter endovascular closure since 1971. We describe a new technique for PDA closure by video surgery. With the patient under general anesthesia and intubated, two 5 mm holes were made through the left thoracic wall. A video camera and specially devised surgical tools were introduced, such as scissors, dissecting forceps, clip appliers. The ductus was dissected and two titanium clips were applied, completely interrupting the ductus. 282 patients were operated on from April 1991. Mean age was 20 months (range 1 month to 17 years) and mean weight was 13 kg (range 1.2 to 65 kg) Twenty-one had associated lesions not necessitating immediate surgical treatment. All had successful closure of the patent ductus with the video-assisted technique. 6 patients had recurrent laryngeal nerve injury (5 transient, 1 permanent). The usual hospital stay was from 48h to 72h. There were no other complications and no deaths. Video surgery is a rapid, safe and successful technique for closure of the patient ductus arteriosus. The technique is feasible in low-weight and premature infants.

[Treatment of ventricular tachycardia in infancy and childhood with amiodarone]. / Traitement des tachycardies ventriculaires du nourrisson et de l'enfant par l'amiodarone.

Ventricular tachycardia, especially in its apparently primary form, is rare in children and difficult to treat, often requiring aggressive methods of reduction or antiarrhythmic drugs unsuited for paediatric practice. Therefore, we investigated the use of amiodarone whose efficacity in the treatment of resistant ventricular tachycardia and good tolerance in children have been established. Three infants, aged from 9 to 15 months, and two children aged 6 and 7 years with apparently primary VT were selected. Etiological investigations were negative in four cases but in one of the older children a left ventricular fibroma was diagnosed and removed surgically. Amiodarone was administered orally at a dose of 500 mg/m2/24 hrs for 5 to 15 days, and then 250 mg/m2/24 hrs for one month in the surgical patient and for 9 to 39 months in the four "idiopathic" cases. Reduction of VT was obtained in all cases 8 to 48 hours after the first dose. There was only one recurrence, attributed to an over-rapid reducing in dosage; it quickly regressed after returning to the initial dosage. Stable sinus rhythm was maintained at long-term: 18 months, 2 years and 5 years after tailing off a course of 20, 40 and 1 month's treatment in 3 children. These cases are considered to be cured, but in one of these children two courses of amiodarone were required, the second for a relapse 3 months after stopping a 9 month's course of therapy. The other two children are still under treatment after 9 and 15 months with no recurrences. There were no hemodynamic, ocular or thyroid side effects. On the other hand, three cases of photosensitivity, two minor and one major requiring termination of therapy after a 20 months course, were observed. In conclusion, amiodarone would appear to be the treatment of choice for ventricular tachycardia in children, reduction of the arrhythmia being obtained in all cases even by oral administration within reasonable limits: its prophylactic value is excellent and clinical tolerance very satisfactory: a definitive cure can be hoped for an idiopathic VT providing that maintenance therapy has been sufficiently prolonged (2 years).

[Long-term results of 156 Mustard operations for simple transposition of the great vessels]. / Résultats à long terme de 156 interventions de Mustard pour transposition simple des gros vaisseaux.

156 children with simple transposition of the great vessels have been operated on by Mustard's technique between 1-6-1967 and 31-12-1976, with an immediate overall mortality rate of 8%. In the longterm, the 9% of late deaths and more especially the complications are regrettable; complications were either of severe arrhythmia (almost 30%) leading to 2 late deaths and 7 pacemaker implantations, or venous obstruction relating to problems with the patch (25%). Despite the improved techniques and consequent reduction in surgical mortality and late complications, longterm prognosis is still unsure because of the unknown fate of the intra-atrial partition, and that of the "passive" rhythms which are so commonly found after this type of surgery.

[Arrhythmia after atrial correction of transposition of the great vessels. Holter recording study of 123 surgically treated patients]. / Troubles du rythme après corrections atriales des transpositions des gros vaisseaux. Etude par enregistrement Holter de 123 opérés.

Sinus node dysfunction after intra-atrial repair of transposition of the great arteries by a Mustard or Senning procedure is well known. We undertook this study to evaluate the frequency, the nature, the severity and evolution of these dysrhythmias by performing Holter monitoring in 123 children followed up over 5 years; 302 Holter recordings were reviewed. The patients were divided into 3 groups of increasing severity: I = no sinus node dysfunction, II = moderate sinus node dysfunction, III = severe sinus node dysfunction with bradycardia of less than 30/min and/or pauses of over 2000 ms. The association of atrial hyperexcitability was classified in 3 subgroups: A = no extrasystoles, B = at least 4 extrasystoles per 24 hours, C = atrial tachycardia (focal tachycardia or flutter) after the first six postoperative months. There were only 15% of normal recordings (IA) and the majority of children (58%) were classified in the intermediary groups (IB, IIA and IIB). Sinus node dysfunction tended to become more severe with time in nearly 30% of the 69 cases followed up sequentially. The bradycardia tended to become more severe and associated with episodes of atrial tachycardia: the frequency of type B and C increased to 30% in Group I, to 68% in Group II and to 91% in Group III. The attacks were severe, especially in patients with a mediocre postoperative haemodynamic result. This explains the global mortality of 3%, the morbidity of 15% and the pacemaker implantation rate of 12%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the systolic pressure of the right ventricle by echocardiographic study of left ventricular geometry]. / Estimation de la pression systolique du ventricule droit par l'étude échocardiographique de la géométrie ventriculaire gauche.

Right ventricular systolic pressure is an important parameter in paediatric cardiology. A critical haemodynamic situation is attained if it exceeds the systemic pressure: strain proximal to severe pulmonary stenosis or the result of pulmonary hypertension. In these circumstances, the patient must be closely followed up at the least, and appropriate treatment, often surgical, has to be instituted. Ambulatory methods of assessing this parameter are either unreliable, like the surface electrocardiogram, or relatively complex, like certain ultrasonic methods. We therefore looked for a method relating the systolic pressures of the two ventricles and the end systolic geometry of the left ventricle as assessed simply from a short axis view of the left ventricle at the level of the junction between the chordae and papillary muscles. Two orthogonal diameters are measured and the ratio of the two dimensions calculated: this ratio which we call the "septal curvature" reflects left ventricular compression by the pressure that the right ventricle exerts through the interventricular septum. Seventy-two children aged 6 hours to 18 years (average 5.2 years) hospitalised for pre or post-operative investigation of congenital heart disease were evaluated by this method. The results were compared by statistical analysis with the ratio of ventricular pressures measured directly almost simultaneously during cardiac catheterisation. In general, a linear relation was observed between septal curvature (x) and ratio of pressures (y); y = 0.88, x - 0.63 and R = 0.92.(ABSTRACT TRUNCATED AT 250 WORDS)

[Closure of patent ductus arteriosus by video thoracoscopy in 282 children]. / Fermeture du canal artériel par vidéo-thoracoscopie chez 282 enfants.

Closure of patent ductus arteriosus by video thoracoscopy is a standardised procedure. The authors report their experience of closure of patent ductus arteriosus by video-thoracoscopy from May 1991 to December 1995. The series included 282 patients divided into 3 groups according to age: under 6 months (78 patients, 27.6%), from 6 months to 4 years (135 patients, 42.88%) and over 4 years of age (69 patients, 24.6%) with an average weight of 12.6 kg (range: 1.2 to 65 kg). Symptomatic pulmonary hypertension was observed in 39 cases and 9 children had associated intracardiac malformations (ostium secundum: 3; ventricular septal defect: 5; abnormal pulmonary venous drainage: 1) which were not corrected. The technique consisted of placing two titanium clips in position under video-thoracoscopy to close the ductus. An echo performed immediately afterwards confirmed closure of the ductus. The main complications were: persistence of a shunt (4 cases) at the beginning of our experience requiring immediate reoperation by video-thoracoscopy in 3 cases and by thoracotomy in one case; left recurrent laryngeal nerve palsy in 6 cases (2.1%) with regression in 5 and persistence in one case; one case of postoperative chylothorax which regressed rapidly. There were no fatalities or haemorrhages and no blood transfusions were required in this series. The average operating time was 20 +/- 15 minutes and the duration of hospital stay around 48 hours when the patients were over 6 months old and 72 hours when less than 6 months of age. Video-thoracoscopic closure of patent ductus arteriosus is rapid, safe, economical, it provides excellent results and may be used in children of all ages.

[Problems posed by preparation of the left ventricle for anatomical correction in simple transposition of the great vessels]. / Problèmes posés par la préparation du ventricule gauche à la correction anatomique de la transposition simple des gros vaisseaux.

Surgical correction of simple transposition of the great arteries by arterial detransposition can only be considered if the left ventricle is capable of functioning under systemic conditions. This is possible at birth but the operation is too big for it to succeed. After a few weeks the left ventricle may lose this capacity but it can be induced to redevelop if it is given a systolic stress by pulmonary banding. This was attempted initially in 30 children aged from 5 weeks to 3,5 years old (20 aged less than 2 months) but had to be abandoned for the following reasons: 8 immediate failures due to severe hypoxia and acidemia, 7 left ventricular failures, mainly in 3 children operated after 6 months of age; 7 severe hypoxemias, 5 pulmonary arterial lesions due to banding and/or the systemo-pulmonary anastomosis associated in some cases; in all, there were 8 failures out of the 17 anatomical corrections performed to date in 22 survivors of banding. The criteria of left ventricular readaptation after banding were difficult to determine. The final result did not appear to be related to either the duration of banding, the degree of aortic desaturation, the ratio of ventricular pressures, or to the various echocardiographic indices. Only the initial hypoxemia (less than 50 p. 100 saturation) with respect to the risk of banding, and the age at which banding was performed (over 6 months) with respect to the risk of anatomical correction, appeared to be obvious risk factors. This is the reason for a new protocol at present under study to try to maintain left ventricular growth by banding in the first days of life, so to ensure a more harmonious and effective, and also less dangerous preparation for anatomical correction. Six new born children have been "prepared" in this way: three had adequate loose banding and underwent atrial correction. Very good results were obtained in the other three patients who have already undergone detransposition at 2,5 and 3 months with excellent immediate results. We believe that neonatal pulmonary banding (before 5 days) when aortic saturation after atrioseptostomy is over 50 p. 100, provides a real alternative to the classical methods of treating simple transposition of the great arteries (Mustard or Senning). Anatomical correction can then be carried out a few weeks later under good conditions.

[Complete correction of Fallot's tetralogy in infants. Preliminary results]. / Réparation complète de la tétralogie de Fallot chez le nourrisson. Résultats préliminaires.

Complete repair was undertaken in 28 infants with severe forms of tetralogy of Fallot because severe cyanosis or anoxic spells. Age at operation ranged from 8 days to 11 months (mean: 4,4 months). Among the 24 cases without any other intracardiac defect, there were 6 early deaths related in 4 cases to a wrong indication or a technical error. Re-investigation was performed in 14 out of the 18 survivors from 3 weeks to 6 months post-operatively: the result is good in 10 cases, fair in 1 case, and poor in 3 cases requiring twice a reoperation with 1 further death and 1 good final result. More accuracy in selecting the surgical patients and improvement in operative techniques should result in a further decrease of our early mortality rate. Primary complete repair should therefore become a substantial alternative to the palliative shunts which results seem to be hazardous in the more severe types of the defect.

[Surgical treatment of double outlet left ventricle]. / Traitement chirurgical du ventricule gauche à double issue.

Three young patients with double outlet left ventricle were operated on at the Centre chirurgica Marie-Lannelongue. There was one secondary death. The follow up period of the two survivors is 24 months and 8 months respectively. The diagnosis of this rare congenital abnormality is difficult because of the multiplicity of the anatomical changes and the diversity of the final clinical entity. This is reflected in the attempts at classification. These difficulties are increased by the high incidence of incomplete forms of the condition which gives rise, especially in vivo, to problems of terminology. Echocardiography provides valuable information in the diagnosis of these forms by showing the abnormal relationship between the interventricular septum and the origin of the great vessels. A complete work up is essential before any decision can be made on management. Particular importance is placed on the topographical and morphological features of the atria and ventricles, the connections of the aorta and pulmonary arteries, and the state of the pulmonary tract. Modern surgical techniques have made correction possible in most forms of the disease, but involves complex procedures which leaves doubts on their long term outcome.