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Aortopulmonary (AP) window [6,10] aortic origin of the right pulmonary artery (RPA) [10], and interruption of the aortic arch [3) are each uncommon malformations . Their coexistence provides a complex that is a rare diagnostic challenge .We here report on an infant who had a combination of all these cardiovascular defects, presenting With cyanosis and congestive heart failure . The use of two-dimensional echocardiography (2DE) in the detection of AP window has been previously described (5, 9, 11] as has been that of anomalous origin of the RPA from the ascending aorta [4,5,11] . In our case 2DE detected both the AP window and the aortic origin of the RPA . We also describe the clinical value of the new two-dimensional color Doppler echocardiography (2D color Doppler), as developed by Omoto and associates [7], for the noninvasive visualization of shunting across the aortopulmonary window, in lieu of cineangiography .KEY WORDS : Aortopulmonary window -Twodimensional echocardiography -Color Doppler e chocardiography -Interrupted aortic archAortic origin of the right pulmonary artery Case Report A 2 1-month-old male infant was admitted to Kyoto University Hospital because of progressive dyspnea and cyanosis since six weeks of age . Delivered full-term to a 31-year old gravida 2, the baby had a birth weight of 3750 g and an uneventful neonatal period . On admission he was in cardiorespiratory distress, with a Address reprint requests to : Dr, Kenya Nishioka, Department of Pediatrics, Kyoto University Hospital, Kyoto 606, Japan .Pediatric Cardiology 00 Springer-Verlag New York Inc . 1986 heart rate of 165/min, respiratory rate of 951min, temperature of 37 .5°C, and body weight of 4700 g . He had cyanosis of the lips and nail beds, flaring of the nasal alae, intercostal and subcostal retractions, wheezes and rates in both lungs, a grade 1-2/6 ejection systolic murmer at the upper left sternal border, hepatomegaly, and Erb's palsy of the left arm . Systolic blood pressure determinations by the Doppler method showed mmHg to be 152 in the right arm, 150 in the left arm, and 75 in the left leg (an intravenous infusion was being given in the right leg) . The patient was in respiratory acidosis (pH = 7, Pco 2 = 83 mmHg, and Pot = 48 mmHg) . The ECG showed a QRS axis of + 120°, incomplete right bundle branch block, and right ventricular (RV) and right atrial (RA) hypertrophy . The chest x-ray showed cardiornegaly (cardiothoracic ratio = 0 .69), RV and RA enlargement, and pulmonary hypervascularity .Using as a two-dimensional echocardiograph the HewlettPackard 77020A Imaging System and a 5-MHz transducer, the parasternal short-axis view at the level of the aortic valve showed normally related great arteries and normal coronary arteries arising from the right-sided and posteriorly positioned great artery . The high parasternal short-axis view (Fig . 1), with slight anterosuperior angulation of the transducer revealed, above the level of the semilunar valves, a defect (12 mm) between the ascending aorta and the main pulmonary ...

Progress in the techniques for surgical implantation of the artificial heart has progressed in parallel with the technology and design of the prosthesis. In the author's first experience with total artificial heart (TAH) implantation (1968) a trans‐sternal split was used opening the sixth intercostal space on the right side across the sternum to the left space. This obviously was not the optimum approach but the complexity, design and size of the prosthesis required maximum exposure of the atria and great vessels. Subsequently the mid‐sternal split incision was used. The Dacron fibril* coated silicone rubber 8 cm Kwan‐Gett ventricles implanted by the mid‐sternal split sustained a calf for 14 days in 1972. A calf with the improved Jarvik 3 ventricles fabricated with the same material and implanted via mid‐sternal split survived 19 days in early 1973. The surgical techniques for lateral (right) thoracotomy were adopted in this laboratory in 1973. These techniques were applicable only when the prostheses fit better in the chest. This procedure has been adopted by other laboratories replacing the natural heart of the calf with a TAH. This report describes in detail the stepwise procedure for implantation of the total artificial heart by a lateral thoracotomy in the calf.