confirmation of congenital heart lesions in the foetus, the care of children with acquired heart disease and the investigation of innocent murmurs of childhood. There is a local perception that the demand for these services far exceeds the available skills in South Africa. In addition to the cardiological needs of our population, the need for surgery for children with heart lesions appears

It is rare to find congenital cardiac disease in association with familial primary hypertrophic osteoarthropathy. We have now encountered three siblings, two of whom had digital clubbing, patent arterial ducts and delayed closure of the cranial fontanels. The third infant was unusual in that there was no clubbing, or cranial abnormality, despite a small ventricular septal defect. To the best of our knowledge, this association has not previously been observed.

Objective-To document the development of aortic regurgitation following occlusion of a patent arterial duct. Design-Case series involving nine children referred for surgical ligation of an isolated patent arterial duct. Setting-Academic referral centre. Methods-A preoperative transthoracic and transoesophageal echocardiogram was performed in theatre to look for aortic regurgitation. Thereafter, aortic flow was monitored throughout the operation by colour flow mapping with the transoesophageal probe in situ. Onset of aortic regurgitation was documented. An inumediate postoperative transthoracic echocardiogram was performed on all patients and then daily until discharge on day 5. A follow up clinical and echocardiographic assessment was performed six weeks postoperatively. Results-With ligation ofthe patent arterial duct, transoesophageal echocardiography showed immediate regurgitation in seven of the nine patients, seen as a small central jet on colour flow mapping. Six of the seven patients continued to have aortic regurgitation on transthoracic echocardiography before leaving theatre. In none was aortic regurgitation audible clinically. At discharge, five patients still had evidence of aortic regurgitation; of four seen at follow up six weeks later, only one had residual regurgitation.Conclusions-Ligation of the patent arterial duct results in the acute termination of the "run off" in a volume overloaded situation. This, together with a rise in the peripheral vascular resistance and the persistence of increased proximal vascular capacitance, is considered to be the underlying aetiology of the acquired aortic regurgitation.

Optimal paediatric cardiac services in South Africa-what do we need? Providing comprehensive care for children with heart disease requires an integrated team of interdependent health practitioners.The team members include cardiologists, cardiothoracic surgeons, anaesthetists, intensivists, cardiac technologists, perfusionists,nurses,socialworkersandphysiotherapists.Theseteam members provide special, very specific skills in dealing with this groupofpatients.Thecareofthesepatientsoftenneedstocontinue into adulthood and adult cardiologists with the necessary training to care for congenital heart disease in adults are essential. Weaknesses or a deficiency at any level, or the inability of the team to function together seamlessly, seriously compromises patientcare.