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The management and results of treatment in 181 children with coarctation of the aorta are presented. In this series, 79% of the patients presented in the first year of life and 55% presented as neonates. One hundred and fifty patients were operated on, with a total surgical mortality of 21%. Only one surgical death occurred in those operated on after 3 months of age. The higher mortality in young infants is closely related to associated cardiac anomalies and to the frequency of aortic and isthmal hypoplasia. Our findings suggest that neonates presenting with heart failure and coarctation should be operated on early, as the surgical mortality under 6 weeks is 45%, whereas there is an 86% mortality in neonates who were not operated on. Analysis of follow-up indicates that when operation can be performed electively the optimal period for sugical treatment is between 6 months and 1 year of age. If operation is performed after this age, there may be persistent systemic hypertension despite relief of aortic obstruction.

M. (1975). Archives of Disease in Childhood, 50, 542. Assessment of Doppler ultrasound to measure systolic and diastolic blood pressures in infants and young children. A recently developed instrument uses the Doppler shift technique to detect vessel wall movement, and it has been suggested that in conjunction with a conventional sphygmomanometer systolic and diastolic blood pressures can be measured. A controlled study was carried out in 20 children recovering from cardiac surgery where direct intra-arterial measurements (one observer) were compared with independent measurements using the Doppler instrument (2 observers). Systolic pressures measured directly and by Doppler technique correlated well and there was no significant difference between intra-arterial and indirect measurements whether the latter were taken by doctors or by nurses. In contrast, direct and indirect diastolic pressure measurements correlated poorly and were significantly overestimated with a mean difference of 6 25 mmHg (range+25 to-10) for doctors, and 4 25 mmHg (range + 20 to -10) for nurses. Thus, the instrument adequately measured systolic blood pressure, but in our hands did not give precise measurements for diastolic blood pressure.We have previously shown that measurement of systolic pressures in children by means of the Parks 802 Doppler* instrument did not exhibit any significant difference from direct intra-arterial pressure measurements (Elseed, Shinebourne, and Joseph, 1973). However, the Parks instrument did not allow measurement of diastolic pressure, a facility reputedly available with the Arteriosonde (Roche).tIn this study, systolic and diastolic pressures obtained with the latter instrument were again compared with direct measurements taken via arterial cannulation. MethodAll studies were carried out on children in the postoperative period after cardiac surgery. Children with coarctation, Blalock-Taussig shunts, or other conditions

Coarctation of the aorta was observed in 2 infants after surgical interruption of the ductus arteriosus. In a further 3 patients transient, but severe, upper limb hypertension in the postoperative period required antihypertensive therapy. The relevance of these findings to the pathogenesis ofjuxtaductal coarctation is discussed and their surgical importance is stressed, as the situation can be easily corrected if recognized on the operating table. Rudolph (I970) and Rudolph, Heymann, and Spitznas (I972) recently reported aortic obstruction becoming evident in neonates who at, or soon after, birth had no clinical evidence of coarctation. They suggested that while the ductus remained open it acted as a conduit bypassing the site of potential obstruction in the aortic lumen. With postnatal constriction, a pressure gradient developed at the junction of the aortic isthmus with the descending aorta, producing juxtaductal coarctation. They were able to simulate this experimentally in fetal lambs. The human counterpart of this experimental work, namely production of a pressure difference between ascending and descending aorta, after surgical interruption of the ductus, has not been adequately documented. The object of this paper is to describe the development of such a pressure difference in 2 infants who subsequently required resection of a localized juxtaductal coarctation. Transient upper limb hypertension developed in a further 3 infants after operation. The findings in the 5 patients are then considered in relation to the pathogenesis of coarctation (Shinebourne and Elseed, I974) and surgical management of persistent ductus arteriosus in infancy. Case histories Case i A baby girl, born on 4 August I97I, birthweight 2-3 kg, was kept in a premature unit for 2 weeks. At 6 weeks there was onset of difficulty with feeding, associated with failure to gain weight. She was admitted to Brompton Hospital aged Iii weeks with heart failure and a cardiac murmur.