Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 1668 Small font size Default font size Increase font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Case Report
    Article Tables

 Article Access Statistics
    PDF Downloaded1072    
    Comments [Add]    
    Cited by others 9    

Recommend this journal


CASE REPORT Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 1  |  Page : 64-68
Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure

1 Department of Anesthesiology, GB Pant Hospital, New Delhi, India
2 Department of CTVS, GB Pant Hospital, New Delhi, India

Click here for correspondence address and email

Date of Submission31-Jul-2009
Date of Acceptance29-Sep-2009
Date of Web Publication11-Jan-2010


Asymptomatic women with mild aortic stenosis (AS) and normal left ventricular functions can successfully carry pregnancy to term and have vaginal deliveries. However, severe AS (valve area <1.0cm 2 ) can result in rapid clinical deterioration and maternal and fetal mortality. So, these patients require treatment of AS before conception or during pregnancy preferably in the second trimester. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk. It can also be used as a palliative procedure allowing deferral of aortic valve replacement until after delivery. The present patient had severe critical AS with congestive heart failure that was refractory to medical therapy and the fetus was viable (>28wks). So, combined lower segment cesarean section and aortic valve replacement were performed under opioid based general anesthesia technique to reduce the cardiac morbidity and mortality.

Keywords: Aortic stenosis, pregnancy, congestive heart failure, cesarean section, aortic valve replacement, general anesthesia

How to cite this article:
Datt V, Tempe DK, Virmani S, Datta D, Garg M, Banerjee A, Tomar AS. Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure. Ann Card Anaesth 2010;13:64-8

How to cite this URL:
Datt V, Tempe DK, Virmani S, Datta D, Garg M, Banerjee A, Tomar AS. Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure. Ann Card Anaesth [serial online] 2010 [cited 2023 Feb 9];13:64-8. Available from:

   Introduction Top

Pregnancy in patients with aortic stenosis (AS) is uncommon but may coexist in patients with AS due to congenital bicuspid aortic valve or rheumatic heart disease. Mild to moderate AS is well tolerated during pregnancy, but critical AS can rapidly deteriorate the hemodynamics and precipitate congestive heart failure (CHF), carrying a high risk for maternal and foetal mortality. [1] Therefore, treatment of severe critical AS with percutaneous balloon aortic valvotomy (BAV) or aortic valve replacement (AVR) [1],[2],[3] is advised before pregnancy and medical termination of pregnancy (MTP) is strongly considered in a symptomatic patient in the first trimester. [4] However, a few authors have reported that with improvements in the surgical and anesthetic techniques, cardiac surgery is an acceptable and sometimes preferable alternative to the medical management of ante-partum cardiac disease and maternal and foetal mortality is much lower than previously reported. [4],[5],[6] When the fetus is viable (>28 wks) and symptoms of CHF are present, lower segment cesarean section (LSCS) and concomitant AVR can be performed to reduce the cardiac morbidity and mortality. To the best of our knowledge there are only two such reports of combined AVR and LSCS in parturients with severe AS in the literature. [7] This case report also describes the successful anesthetic management of a parturient with severe AS with congestive heart failure undergoing simultaneous emergency LSCS, followed by AVR and proposes recommendations for the management of AS during pregnancy.

   Case Report Top

A 28-year-old, weighing 40 kg, height 155 cm, BSA 1.33 m 2 , primigravida, with severe congenital AS presented in CHF with functional capacity IV (New York Heart Association functional classification). In view of severe critical AS and CHF, the patient was transferred to our institute for LSCS and concomitant AVR. Her heart rate was 120/min and arterial pressure was 90/60 mm Hg. She had bilateral basal crepitations and pedal edema. Airway assessment revealed easy tracheal intubation (Mallampati class -1). Obstetrical examination confirmed fundal height of 31 weeks gestation and fetal heart rate (FHR) of 140 beats/min. Arterial blood gas analysis showed carbon dioxide tension (PaCO 2 ) of 36 mm Hg, oxygen tension (PaO 2 ) 76.0 mm Hg, oxygen saturation 91.0%, PH 7.31, and base excess ­of -7.8 that was corrected with sodium bicarbonate (50 ml). Chest X-ray showed cardiomegaly with bilateral pulmonary congestion; ECG revealed sinus rhythm and left ventricular hypertrophy (LVH). Echocardiography revealed bicuspid aortic valve, thickened leaflets, severe AS with aortic valve area 0.7cm 2 , pressure gradient across aortic valve (peak/mean) 100/54 mm Hg, concentric LVH, ejection fraction of 60%, and right ventricular systolic pressure of 64 mm Hg. There was no aortic and mitral valve regurgitation. She was nursed in left lateral position and put on frusemide (40 mg i.v., thrice daily), oral potassium, intravenous (IV) infusion of dobutamine (7.5 µg/kg/min), IV infusion dopamine (5 µg/kg/min), and oxygen therapy with mask. A stethoscope was taped to her abdomen to monitor the fetal heart sounds (FHS) (cardiotocographic monitoring was not available in our institution). The plan was to first perform sternotomy and cannulate the aorta and right atrium in readiness to institute CPB and then perform LSCS to minimize maternal and fetal risk. However, fetal assessment in the operation room before induction of anesthesia revealed severe distress (FHR<80/ min), so it was decided to perform LSCS urgently and defer the sternotomy. The patient received all cardiac medications in the morning and metoclopramide (10 mg i.v.) and ranitidine (150 mg i.v.), five minutes prior to induction of anesthesia as prophylaxis for acid aspiration syndrome. Placement of large venous, arterial and right internal jugular vein triple lumen central venous line were performed under local anesthesia. The chest and abdomen were cleaned and draped. Induction of anesthesia was performed using increments of fentanyl (150 µg+100 µg), thiopentone sodium (50+50 mg), and rocuronium (40 mg) was used to facilitate endotracheal intubation. Fractional inspired oxygen concentration (FiO 2 ) of 1.0 was used throughout the procedure. After the induction of anesthesia, systolic blood pressure was between 96 to112 mm Hg, mean arterial pressure was 82±12 mm Hg and heart rate was 90-100 beats/min. The hemodynamics remained stable throughout the procedure. A female baby weighing 1.75 kg and APGAR score of 5 at one minute was delivered. The baby was cyanosed and did not cry after birth, and was immediately intubated, manually ventilated and thereafter transferred to the neonatal intensive care unit (ICU). Simultaneously, uterine muscle tone was achieved with the use of uterine massage with hot sponges, oxytocin infusion (10 units/hr) and intramuscular prostaglandin (0.25 mg) and abdomen was packed with large hot sponges. Induction-delivery, abdominal skin incision-delivery and uterine incision - delivery times were 10 mins, 8 mins, and 3 mins, respectively. After delivery of the foetus, anesthesia was supplemented with intermittent midazolam, fentanyl and vecuronium bromide. A continuous infusion of propofol (100-300 µg/kg/hr) was used to maintain adequate depth of anesthesia. AVR was performed with an 18 mm ATS mechanical valve (ATS medical Inc. Minneapolis, MN 55447, USA) under standard CPB techniques with moderate hypothermia (29°C). Patient was weaned off CPB with the infusions of epinephrine (0.05 µg/kg/min), dopamine (5 µg/kg/min) and nitroglycerin (1 µg/kg/min). Anticoagulation was neutralized with protamine (120 mg). The sternum was closed after protamine administration, following which the abdomen was closed. Total CPB time was 118 min and ischemia time was 85 min. Patient was transferred to the ICU for elective ventilation and extubated after 20 hours. The baby was extubated after 48 hours. Further course was uneventful and both mother and child were discharged from the hospital in a satisfactory condition.

   Discussion Top

Experience with pregnancy in patients with congenital bicuspid AS is uncommon, because it is more commonly found in men, and severe stenosis is unusual in women of childbearing age. [8],[9] Severe critical AS is an important non-obstetric cause of maternal and fetal morbidity and mortality during pregnancy. [9],[10],[11]

Asymptomatic women with mild obstruction and normal LV systolic function before conception will in general tolerate pregnancy well and can be managed conservatively throughout the pregnancy, [2] while those with symptoms or severe stenosis (valve area <0.5 cm 2 m 2 , mean gradient >60 mm Hg) are at a risk of acute left ventricular failure. [12] The major maternal concern in the pregnant patients with congenital AS is deterioration in their cardiac status due to physiological changes of pregnancy in the form of increased blood volume, heart rate, cardiac output, and decreased systemic vascular resistance. Also, a decrease in venous return because of hypovolemia, vasodilatation, or aorto-caval compression, especially in the peripartum period can lead to low cardiac output, myocardial and placental ischemia, pulmonary congestion and sudden death. [10],[13]

Symptomatic patients with critical AS should be appropriately counseled for delaying conception until treatment of AS can be obtained. [2],[3],[14] However, if cardiac surgery is necessary in a pregnant patient, it should be undertaken as early as possible in the gestation; preferably in the second trimester after the completion of organogenesis. [11],[15] Brazilian consensus on heart disease and pregnancy recommends the surgical treatment for severe bicuspid AS at any stage during gestation when the gradient across the valve is greater than 70 mm Hg. [16] Pregnant patient with mild to moderate AS or those with severe AS who are asymptomatic or have mild symptoms can be managed conservatively during pregnancy with bed rest, beta blockers, and oxygen. In these patients, vaginal or cesarean delivery with optimal pain control and invasive hemodynamic monitoring is recommended unless contraindicated for obstetric reasons followed by valve surgery in the postpartum period if needed. [12],[17] Once AS progresses to cardiac decompensation and presents with CHF, BAV or AVR should be considered as life saving procedures before labor and delivery. [9],[18],[19],[20] BAV can also be used as a palliative procedure allowing deferral of AVR until after the delivery. [20],[21]

Strickland et al. in 1991 have reported combined LSCS and AVR in two parturients with severe AS who developed cardiac failure due to increased demand of pregnancy, but a patient who had severe aortic prosthetic valve thrombosis could not be separated from the CBP and died during the procedure. [7] The present patient also had severe critical AS with cardiac decompensation that was refractory to medical therapy and the fetus was viable. So, combined LSCS and AVR were performed, as combined procedures are well established techniques now-a-days. Some authors have performed AVR in the third trimester and then allowed the pregnancy to continue till term. [9] However, with this approach, the fetus may be at risk due to deleterious effects of the CPB. The various treatment modalities according to the length of pregnancy and hemodynamic status of a pregnant patient with AS are summarized in [Table 1].

The goals of hemodynamic management should be to maintain sinus rhythm, normal heart rate, preserve cardiac contractility, avoid myocardial depression, and maintain preload and SVR. The uterus should be displaced leftward to minimize the effect of aortocaval compression, as any decrease in preload is poorly tolerated. Conversely, small increases in vascular volume may produce dramatic increase in filling pressure resulting in pulmonary edema. [13],[22] Various primary anesthetic techniques have been used including etomidate, opioids, isoflurane, ketamine, thiopentone, and propofol. [7],[22],[23] Despite the risk of fetal depression, in the interest of maternal safety, opioid induction can be used as it provides hemodynamic stability. [24] In this respect, remifentanil (2-4 µg/kg) seems to be an ideal agent. It has been shown to provide cardiovascular stability in conjunction with rapid induction and emergence from anesthesia in parturient and minimum side effects in neonate. [13],[24] The authors used a modest dose of fentanyl (5 µg/ kg) during induction of anesthesia, as remifentanil is not yet available in the country. Inhalational agents were avoided, as these can produce uterine relaxation, myocardial depression, and decrease in systemic vascular resistance, and rhythm disturbances. Although hemodynamic stability was achieved, the authors believe that respiratory depression of the fetus may be due to the use of opioids besides the fetal prematurity.

Hypotension and hypertension pose the risk of myocardial ischemia, and hence, should be promptly treated. Vecuronium decreases the heart rate and should be preferred in patients with faster baseline heart rates; and rocuronium may be useful for rapid sequence induction. A pulmonary artery catheter can be useful but carries the risks of inducing serious ventricular arrhythmias and cardiovascular collapse. [22] The authors preferred to use a CVP catheter. Transesophageal echocardiography, if available is yet another useful option to monitor the hemodynamics. Intravenous bolus injection of oxytocin at delivery can cause severe hypotension, hence should be avoided. [25]

Although in the present patient, AVR was performed after LSCS, it is worthwhile to discuss the factors that can improve the fetal outcome of open heart surgery during pregnancy. The recommendations for CPB in the gravid patient are based on the objective to sustain adequate foeto-maternal gas exchange in view of the increased cardiac output of 30-60% above nonpregnant values: 1) use of normothermic or mild hypothermic (32-34°C) perfusion when feasible; 2) maintaining pump flow rates >2.5 L/min/m 2 , and a mean arterial pressure above 70 mm Hg (70 to 90 mm Hg); 3) minimum hemodilution (hematocrit >29%; 4) high PaO 2 (200-400 mmHg); 5) use of membrane oxygenator; 6) use of alpha stat pH management; 7) using pulsatile flow; 8) beating heart surgery is particularly desirable in parturients whose foetuses are at risk of hypothermia, hemodilution, and hyperkalemia during CPB; 9) keeping minimum bypass and ischemia time; 10) monitoring fetal heart rate and recording uterine contractions. [3],[11],[15],[26],[27],[28],[29]

In conclusion, the present case report demonstrates that LSCS with concomitant AVR can be safely performed under opioid-based general anesthesia technique in pregnant patient with critical AS. But, severe respiratory depression in the new born must be anticipated with the use of fentanyl.

   References Top

1.Baum VC. Congenital heart disease in adults, In Kaplan JA (ed): Cardiac anaesthesia (ed 5). Phladelphia, PA, WB Saunders; 2006. pp. 705-21.  Back to cited text no. 1      
2.Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:84-231.  Back to cited text no. 2      
3.Aranyosi J Jr, Aranyosi J, Péterffy A. Pregnancy and cardiac surgery with cardiopulmonary bypass. Magy Seb 2008;61:17-21.  Back to cited text no. 3      
4.Lao TT, Sermer M, MaGee L, Farine D, Colman JM. Congenital aortic stenosis and pregnancy--a reappraisal. Am J Obstet Gynecol 1993;169:540-5.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Silversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol 2003;91:1386-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Vincelj J, Sokol I, Pevec D, Sutliæ Z. Infective endocarditis of aortic valve during pregnancy: a case report. Int J Cardiol 2008;126:10-2.  Back to cited text no. 6      
7.Strickland RA, Oliver WC Jr, Chantigian RC, Ney JA, Danielson GK. Anesthesia, cardiopulmonary bypass, and the pregnant patient. Mayo Clin Proc 1991;66:411-29.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysiological implications of a bicuspid aortic valve. Circulation 2002;106:900-4.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Ben-Ami M, Battino S, Rosenfeld T, Marin G, Shalev E. Aortic valve replacement during pregnancy. A case report and review of the literature. Acta Obstet Gynecol Scand 1990;69:651-3.  Back to cited text no. 9      
10.Tumelero RT, Duda NT, Tognon AP, Sartori I, Giongo S. Percutaneous balloon aortic valvuloplasty in a pregnant adolescent. Arq Bras Cardiol 2003;82:98-101.  Back to cited text no. 10      
11.Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth Analg 2009;108:777-85.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Naidoo DP, Moodley J. Management of the critically ill cardiac patient. Best Pract Res Clin Obstet Gynaecol 2001;15:523-44.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Wong AYC. Use of remifentanil in general anaesthesia for emergency caesarean section in patient with severe heart diseases and pulmonary arterial hypertension. Int J Anae 2008;15:2.  Back to cited text no. 13      
14.Tzemos N, Silversides CK, Colman JM, Therrien J, Webb GD, Mason J, et al. Late cardiac outcomes after pregnancy in women with congenital aortic stenosis. Am Heart J 2009;157:474-80.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Talwar S, Kale SC, Kumar L, Sabu R, Kumar AS. Open heart surgery during pregnancy. Ind J Thorac Card Vasc Surg 2003;19:184-5.  Back to cited text no. 15      
16.Consenso Brasileiro SobreCardiopatia e Gravidez. Arq Bras Cardiol 1999;72:5-26  Back to cited text no. 16      
17.Seeliger T, Schild RL, Koch A, Weyand M, Flachskampf FA. Congenital aortic valve stenosis with very high pressure gradient in a pregnant patient. Dtsch Med Wochenschr 2008;133:2272-4.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Weiss BM, von Segesser LK, Alon E, Seifert B, Turina MI. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. Am J Obstet Gynecol 1998;179:1643-53.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Radford DJ, Walters DL. Balloon aortic valvotomy in pregnancy. Aust N Z J Obstet Gynaecol 2004;44:577-9.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Myerson SG, Mitchell AR, Ormerod OJ, Banning AP. What is the role of balloon dilatation for severe aortic stenosis during pregnancy? J Heart Valve Dis 2005;14:147-50.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, et al. Aortic stenosis: An underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med 2004;116:8-13.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Cook DJ, Housmans PR, Rehfeldt KH. Valvular heart disease: Replacement and Repair, In Kaplan JA(ed): Cardiac Anesthesia(ed 5). Philadelphia, PA,WB Saunders; 2006. pp. 645-90.  Back to cited text no. 22      
23.Bendel S, Ruokonen E, Pölönen P, Uusaro A. Propofol causes more hypotension than etomidate in patients with severe aortic stenosis: A double-blind, randomized study comparing propofol and etomidate. Acta Anesthesiol Scand 2007;51:284-9.   Back to cited text no. 23      
24.Orme RM, Grange CS, Ainsworth QP, Grebenik CR. General anaesthesia using remifentanil for caesarean section in parturients with critical aortic stenosis: a series of four cases. Int J Obstet Anesth 2004;13:183-7.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]  
25.Yentis SM, Dob DP. Caesarean section in the presence of aortic stenosis. Anesthesia 1998;53:606-7.  Back to cited text no. 25      
26.Kuczkowski KM, van Zundert A. Anesthesia for pregnant women with valvular heart disease: The state-of-the-art. J Anesth 2007;21:252-57.  Back to cited text no. 26      
27.Pomini F, Mercogliano D, Cavalletti C, Caruso A, Pomini P. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg 1996;61:259-68.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]  
28.Tehrani H, Masroor S, Lombardi P, Rosenkranz E, Salerno T. Beating heart aortic valve replacement in a pregnant patient. J Card Surg 2004;19:57-8.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]  
29.Shastri C, Kane D, Shroff PP, Aravind A. Cardiopulmonary bypass in pregnancy: An experience of three different clinical scenarios. The int J Ana 2007;12:1.  Back to cited text no. 29      

Correspondence Address:
Vishnu Datt
Department of Anesthesiology and Intensive Care, Room No. 619, 6th Floor, Academic Block, GB Pant Hospital, New Delhi-110002
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.58838

Rights and Permissions


  [Table 1]

This article has been cited by
1 Goal-directed fluid therapy and combined spinal-epidural anesthesia in management of pregnant woman with severe aortic stenosis
Cheng-Hsu Lu, Szu-Ling Chang, Hsiu-Wei Su, Chih-Chung Tsai, Hui-Chin Lai
Medicine: Case Reports and Study Protocols. 2022; 3(10): e0231
[Pubmed] | [DOI]
2 Anesthesia Management of Simultaneous Cesarean Section and Valve Replacement: A Tight-rope Walk Twice!
Shakuntala Basantwani, Bharati A Tendolkar, Ruchi A Jain, Surabhi Nellore
Journal of Research & Innovation in Anesthesia. 2018; 3(1): 22
[Pubmed] | [DOI]
3 Pregnancy in a Patient With Severe Aortic Stenosis Requiring Unusual Management
Liana Valeanu,Jean-Pol Depoix,Daniel Enguerand,Laura Tini,Marie-Pierre Dilly,Richard Raffoul,Agnes Bourgeois-Moine,Mandovi Rajguru,Daniel Longrois,Bernard Iung,Philippe Montravers
Journal of Cardiothoracic and Vascular Anesthesia. 2015;
[Pubmed] | [DOI]
4 Bicuspid aortic valve in pregnancy
Shi-Min Yuan
Taiwanese Journal of Obstetrics and Gynecology. 2014; 53(4): 476
[Pubmed] | [DOI]
5 Indikationen für kardiopulmonalen Bypass in der Schwangerschaft und Auswirkung auf fetale Sterblichkeit | [Indications for cardiopulmonary bypass during pregnancy and impact on fetal outcomes]
Authors of Document Yuan, S.-M.
Source of the Document Geburtshilfe und Frauenheilkunde. 2014;
6 result 2 Document Anesthetic management of a simultaneous emergency craniotomy and cesarean delivery
Wouters, B., Sanford, D.B.
Source of the Document AANA Journal. 2013;
7 Postpartum aortic dissection
Shi-Min Yuan
Taiwanese Journal of Obstetrics and Gynecology. 2013; 52(3): 318
[Pubmed] | [DOI]
8 Transesophageal echocardiography and intraoperative phlebotomy during surgical repair of coarctation of aorta in a patient with atrial septal defect, moderately severe mitral regurgitation and severe pulmonary hypertension
Praveen Kumar Neema,Subrata K. Singha,S. Manikandan,Ramesh Chandra Rathod
Journal of Clinical Monitoring and Computing. 2012; 26(3): 217
[Pubmed] | [DOI]
9 Effect of pneumoperitoneum on intracranial pressure during supratentorial craniotomy: A case report
Kataria, S., Rakesh, S.V., Panda, N.B., Bhagat, H., Mukherjee, K.K., Yadav, T.D.
Acta Anaesthesiologica Belgica. 2010; 61(4): 217-220