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As a result of considerable changes in the techniques of cardiopulmonary by-pass at Guy's Hospital since the introduction of hypothermic perfusion, anasthetic management of these cases 1 has required alteration.In some of our earlier cases ventilation was inadequate in the immediate post-operative phase, and it was considered that the anaesthetic technique might have contributed to this state. Therefore, in order to avoid the use of large doses of tubocurarine chloride and pethidine, it was felt that a trial should be made of halothane as the main anasthetic agent.Many types of anasthesia have been used in different centres during cardio-pulmonary by-passzv 3941 536.7. Some of these21 3, emphasize the need for the deliberate production of respiratory alkalosis by overventilation in order to offset the metabolic acidosis which may result from perfusion. We do not consider this necessary or desirable, and choose a ventilatory level delivered by a mechanical ventilator to maintain normal pH and P C O~ levels.This method of anaesthesia has now been used in over 120 cases of all types of open heart surgery, without any post-operative complication directly attributable to the anasthetic technique; it is based on that described by Dawson, Theye and Kirklin 7.

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Failure to carry out planned investigations including echocardiogram left myocarditis undiagnosed resulting in a stroke, cognitive dysfunction and hemiplegia.