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A general review of the main problems found in the management of inoperable heart anomalies is made by the author. He determines the reasons why a heart disease cannot be corrected by surgery, the complications found in such cases, the cautiousness that must be taken and the psychological aspect of these problems in relationship with the family and the patient.

We have studied 44 patients with classical tricuspid atresia who underwent radical surgery between 1971 and 1985. Bypassing of the incomplete and rudimentary right ventricle was performed, in anterior fashion, in 17 patients operated on from 1971 to 1980. Subsequently, from 1980 to 1985, we used a technique of posterior retroaortic atriopulmonary anastomosis. This was undertaken in 27 patients. We have now compared the results in the two groups. Hospital and late mortality was 23.5 and 17.6% in those undergoing an anterior anastomosis, while it was 7.4 and 3.7% in those having a retroaortic connexion. When we compared the results in survivors, according to a previously designed clinical assessment score, we found that 41.1% of those undergoing the anterior approach were in excellent clinical status in comparison to 85.1% of those having a posterior anastomosis. The actuarial survival curve at 6 years showed 88.8% survival (70% confidence limit 44-77) for the posterior approach and 64.7% for the anterior. On the basis of our findings we felt able to remove from consideration as risk factors three of the features initially identified by Choussat and his colleagues. We conclude that better immediate and late results are obtained with the posterior retroaortic approach. We also found that those patients with excellent long-term outcome had postoperative right atrial pressures less than 14 mm Hg. Late arrhythmias were associated with increased right atrial pressures and were a relevant risk factor in both groups.