Objective-To establish the incidence of systolic and diastolic dysfunction of the right and left ventricle in a large cohort of patients after Mustard or Senning operations and to assess changes in the incidence on long term follow up. Design-Postoperative case-control study using radionuclide ventriculography. Ejection fractions, peak filling rates, rapid filling periods and fractions, slow filling periods and fractions, and atrial contraction periods and fractions were studied. Setting-Tertiary care centre, ambulatory and hospital inpatient care. Patients-A convenience sample of 153 patients studied at median age of 6.9 years (median 4.4 years after surgery). In 99 cases another study was available at a median age of 15.3 years (median 13 years after surgery and 8.8 years after the first study). Results-Respective incidences of dysfunction in the first and the second study were as follows: ejection fraction-right ventricle 7.8% and 8.1%, left ventricle 7.2% and 10.1%; peak filling rate-right ventricle 0% and 4.2%, left ventricle 14.3% and 29.5% (p < 0.05); rapid filling periodright ventricle 18.3% and 11.6%, left ventricle 30.2% and 30.5%; slow filling period-right ventricle 4.8% and 3.2%; left ventricle 11.9% and 23.2%; atrial contraction period-right ventricle 0.8% and 4.2%, left ventricle 15.1% and 26.3%; rapid filling fraction-right ventricle both 0%, left ventricle 82.5% and 79.0%; slow filling fraction-right ventricle 0.8% and 4.2%, left ventricle 37.3% and 30.5%; atrial contraction fraction-right ventricle both 0%, left ventricle 79.4% and 71.6%. Conclusions-The incidence of systolic ventricular dysfunction is 8% (right ventricle) and 10% (left ventricle) 13 years after surgery, without a significant increase over the eight year follow up. Diastolic filling is abnormal in up to 80% of patients and left ventricular peak filling rate deteriorates with time.

Conclusions-Radionuclide angiocardiography allows the quantitative analysis of pulmonary blood supply in BCPA with sources of pulsatile blood flow except in patients with cavo-caval collaterals or bilateral BCPA. Non-pulsatile flow from BCPA is mainly directed to the ipsilateral lung, whereas pulsatile flow to the contralateral lung. Total perfusion of the ipsilateral lung is less than the perfusion of the contralateral lung. (Heart 1996;75:513-517) Keywords: congenital heart defects; cavopulmonary anastomosis; radionuclide angiocardiography; pulmonary blood flow.Surgical palliation of complex cardiac anomalies is being done increasingly by total cavopulmonary connection, on the basis that the right heart is dispensable.' In patients who do not fulfil criteria for total cavopulmonary connection2 the results are not satisfactory. We present a new non-invasive method for quantitative assessment of relative contribution of BCPA and the sources of pulsatile blood flow to the total pulmonary blood flow, as well as to the perfusion of each lung. Rationale Radionuclide angiocardiography allows regional flow measurement using a peripheral vein injection and external counting. The pulmonary blood supply in BCPA with a source of pulsatile blood flow consists of venous blood from the superior vena cava and pulsatile arterial blood from aortopulmonary connections or a stenotic pulmonary valve. In this situation, after tracer injection into the drainage area of the superior vena cava, the lung dye dilution curve is composed of two peaks caused by the cavopulmonary and arterial flows respectively. The relative contribution of these two sources to the overall lung perfusion may be calculated using integrals of the two respective parts of dilution curve in a manner similar to the calculation of intracardiac shunts.'718 Furthermore, by analogy to the measurement of cardiac output,'8 19 the total flow through both lungs may be calculated separately and compared. A gamma camera system enables direct visualisation of the superior to inferior vena cava collaterals and regional pulmonary blood flow during the radionuclide angiocardiography. Subsequent

Summary Marked abnormalities of pulmonary blood flow distribution were detected in 13 out of 21 children with cystic fibrosis using lung scanning. Underperfusion of different grade was localized most frequently in the right upper area, followed by the right middle and left upper areas. Correlation between clinical condition or impairment of gas exchange and degree of perfusion disturbances was lacking. Abnormal chest roentgenograms were encountered more frequently than the definite disturbances in the distribution of perfusion. On the other hand, even profound defects of perfusion were not revealed by chest roentgenography. Repeated lung scanning might be helpful in the evaluation of the dynamics of pulmonary involvement in cystic fibrosis.

Aplasia, hypoplasia and stenosis of the pulmonary artery showed, on scintigraphic investigation, unilateral, homogenous decreased in lung perfusion. In 3 of 4 children with pulmonary sequestration there was a difference in blood flow between the two lungs, or in one part of the lung. Isolated anomalous drainage of pulmonary veins does not produce deviations from the normal distribution of blood flowing from the right ventricle into the lungs. Analysis of scinitigraphic findings in 1450 children with cardiopulmonary disease has shown that with an otherwise unexplained marked homogeneous unilateral decrease in flow, we can with great certainty diagnose a developmental defect of the pulmonary vessels. Differences in lung area, judged from the scintigram, are a sensitive indicator of associated disturbances of development of the lung parenchyma. In 26 of 42 such developmental anomalies of the pulmonary vascular bed this finding was demonstrated. Pulmonary scintigraphy is a very valuable complementary method, because of its simplicity and relative safety for the patient, in the diagnosis of congenital anomalies of the pulmonary vasculature, especially in infants and young children.

The result was union in four weeks with about one inch shortening. She died two months later of intercurrent malady, nature not determined. Physicians, Drs. Gray and C. E. Ruth. Case 21.-Tim H., aged 80 years, habits intemperate. Fractured the left femoral neck by a fall on the sidewalk, Nov. 27, 1899. Treated as above. Union was obtained in five weeks; position and motion perfect; shortening one-half inch. Examined and measured leg, April 25, 1900. January, 1901, still well with good use of leg. Physicians, R. H. Fegers and C E. Ruth. Case 22.-Mrs. Obediah H., aged 70. Sustained a fracture of the right femoral neck from a fall in January, 1901. Eight days later I was called, and treatment was begun as in the above-mentioned cases. Union was obtained in four weeks without discoverable shortening. Case 23.-Boy 10 years old fell twenty feet and sustained a fracture of the femoral neck. Treatment as in the former cases, with scarcely demonstrable shortening. Union was secured in four weeks. Physician, A. Ives. The above physician has had two other cases, 73 and 86 years of age, in which union was secured, but death resulted from exhaustion or complications, and as I have not the histories, can furnish no farther report of them. Case 24.-David IS., aged 60 years, April 10, 1900, was thrown from an ore wagon in a runaway, and thrown down the mountain thirty or forty feet. Examination under chloroform revealed fracture of the femoral neck. Treatment as in the former cases for six weeks. Union was obtained with onehalf inch of shortening. He has for several months been driving the ore wagon, and walks with very little limp. Occasionally complains of some pain in the hip in bad weather. Physician, C. M. Tinsman, Adin, Cal. Case 25.-Mrs. Elizabeth F.. aged 86, sustained fracture of the right femoral neck in January, 1900, with shortening, eversion and backward displacement of the trochanter major. Treated by Buck's counter and lateral extension. Union was obtained with no perceptible shortening. The fractured leg gives as good service as before the injury. Physician, Dr. F.