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The performance of the admission day Paediatric

Objective-To assess the immediate haemodynamic improvement and long term symptomatic benefit of percutaneous mitral balloon valvotomy in patients aged over 70 years. Design-Pre-and postprocedure haemodynamic data and follow up for 1 to 10 years by clinic visit or telephone contact. Setting-Tertiary referral centre in Scotland. Subjects-80 patients age 70 and over who had mitral balloon dilatation: 55 were considered unsuitable for surgical treatment because of frailty or associated disease. In an additional four patients mitral dilatation was not achieved. Main outcome measures-Increase in valve area after balloon dilatation and survival, freedom from valve replacement, and symptom class at follow up. Results-Mean (SD) valve area increased by 89% from 0.84 (0.28) to 1.59 (0.67) cm 2 . There was a low rate of serious complications, with only two patients having long term major sequelae. Of 55 patients unsuitable for surgical treatment, 28 (51%) were alive without valve replacement and with improvement by at least one symptom class at one year, and 14 (25%) at five years. In the 25 patients considered suitable for surgical treatment, 16 (64%) achieved this outcome at one year and nine (36%) at five years. Conclusions-Percutaneous mitral balloon valvotomy is a safe and useful palliative procedure in elderly patients who are unsuitable for surgery. Balloon dilatation should also be used for elderly patients whose valve appears suitable for improvement by commissurotomy, but echo score is an imperfect predictor of haemodynamic improvement. (Heart 2000;83:433-438)

Summary Key wordsAnaesthesia; obstetric. Anaesthetic techniques; epidural. Intravenous jluids; Hartmann's, polygelatin (Haemaccel).The many advantages of conduction anaesthesia over general anaesthesia for Caesarean section have been well described by Moir' and the continuing high incidence of deaths from Mendelson's syndrome, failed intubation and hypoxia associated with general anaesthesia2 fuels the present enthusiasm for performing Caesarean sections using epidural analgesia. Conduction anaesthesia, however, poses its own problems, of which hypotension and inadequate analgesia are the most relevant. For adequate analgesia a high block, to at least T6, is necessary and the concomitant vasodilatation predisposes to hypotension, even when great care is taken to avoid aortocaval compression.A widely used method of prophylaxis against hypotension developing during conduction anaesthesia for Caesarean section has been an intravenous preload of 1 litre of crystalloid solution 30 minutes before establishing the nerve block,3 but this has failed to be consistently effective in our experience and that of other^.'^ It was, therefore, decided to invesiigate the incidence of hypotension occurring in patients undergoing Caesarean section with epidural analgesia, preloaded with either intravenous colloid or crystalloid solutions.

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