Ralph D. Alley

The Society of Thoracic Surgeons

The opportunity to discuss evolving socioeconomic issues affecting the medical profession as a whole was rejected in favor of personalizing The Society of Thoracic Surgeons for a membership that has grown to almost 1,500 persons. Drawing on historical insights gained through participation in the origin, growth, and development of The Society, I take readers behind the scenes and introduce to them the many people and vast resources that serve our membership. Particular attention is focused on the services of The Societys headquarters office, which is housed and managed by Smith, Bucklin and Associates, Inc, of Chicago, a multiple-association management firm that serves 60 national organizations; on our prestigious publisher, Little, Brown and Company of Boston; and on its link with our Editorial Office in Ann Arbor.

Pathogenesis of transposition Complexes

Abstract We may now summarize the developmental processes described above as follows : The single endothelial heart tube of the 6 to 8 somite embryo results from the fusion of paired anlagen. With further growth and lengthening of the heart tube, the latter bends ventrally and to the right due to the relatively slower growth of the pericardial cavity. This sigmoid loop formation of necessity imparts to the tube a certain amount of torsion, which may account for the weakly spiral course of the truncoconal swellings that appear at the 6 mm. stage. The truncus swellings at first grow much faster than the conus swellings and fuse, dividing the proximal truncus into aortic and pulmonary channels. The undivided distal truncus and adjacent portion of the ventral aorta dilate concomitantly (trunco-aortic sac). The sixth arches are shifted to the left; the ventral aorta, to the right. The posterior wall of the trunco-aortic sac invaginates to form a vertically disposed septum, the aorticopulmonary septum, which meets and fuses with the truncus septum. Thus the truncus is divided into pulmonary artery and aorta. The conus swellings now grow rapidly in size and bulk until they also have fused with each other and distally with the truncus swellings thus completing the division of the truncoconus. Meanwhile, enlargement of the atrioventricular canal transversely and to the right, and a relative shift and flattening out of the conoventricular flange have brought the posteromedial (aortic) portion of the conus in line with the left ventricle to form the aortic vestibule. It must be emphasized that the proximal ascending aorta, the aortic vestibule, the proximal pulmonary artery and the entire right ventricle are all derived from the bulbus cordis. In the young embryo, therefore, both the aorta and the pulmonary artery originate from the right ventricle, the aorta being transferred secondarily to the left ventricle. The characteristic twist of the two great arteries around each other in the normal adult heart is the result of four developmental processes: (1) torsion due to formation of the cardiac loop, (2) the mode of division of the trunco-aortic area, (3) the transfer of the aortic root to the left ventricle, and (4) growth and dilatation of the two arteries. The sinuses of Valsalva, semilunar valves and the proximal portions of the pulmonary artery and ascending aorta are derived from the truncus arteriosus.

Clinical presentation of rhabdomyoma of the heart in infancy and childhood

Abstract Four infants with cardiac rhabdomyomas were seen during the past 2 years at Albany Medical Center Hospital; 2 were siblings. The presenting cardiac problems in the 4 infants were congestive heart failure, cyanosis secondary to shunt reversal at atrial level, paroxysmal atrial tachycardia and significant subaortic stenosis, respectively. All 4 patients had tuberous sclerosis. Surgical removal of the tumor was performed in 2. The signs and symptoms produced by myocardial dysfunction secondary to the tumor are reviewed. It is pointed out that the cardiac symptoms produced by rhabdomyoma are not specific and can be produced by other types of cardiac tumors. The possibility of having a second child with rhabdomyoma should not be dismissed. Surgical removal of the tumor should be considered when it is producing significant obstruction of the blood flow on either side of the heart.

Cardiac Rhabdomyoma in the Neonate: Surgical Management

Rhabdomyoma is the most common cardiac neoplasm in neonates. Tuberous sclerosis is found in half of the patients with rhabdomyomas. We maintain a surgical policy of accepting for operation only neonates in whom it has been demonstrated that the primary cause for hemodynamic compromise is obstructing, intracavitary neoplasms. Only the intracavitary portions of the rhabdomyoma are excised; no effort is made to completely remove all intramural tumors. Rhabdomyomas demonstrate benign pathological characteristics and may regress. Neonates with rhabdomyomas but no hemodynamic impairment, or those in whom only intramural masses can be demonstrated, are not considered surgical candidates. Tuberous sclerosis by itself should not be judged a contraindication to operation. The results of our surgical policy regarding rhabdomyomas in neonates are reported in two case presentations.

Traumatic Aortic Rupture: An Additional Roentgenographic Sign

Esophageal displacement to the right at the level of the aortic arch and isthmus, as marked by an opaque nasoesophageal tube on anteroposterior chest roentgenogram is a useful sign in diagnosing traumatic aortic rupture. Finding this esophageal displacement in patients with blunt chest trauma warrants an immediate thoracic aortogram for demonstration of possible aortic injury.

Ebstein's malformation of the left atrioventricular valve in corrected transposition, with subpulmonary stenosis and ventricular septal defect.

Abstract A case of left Ebsteins anomaly in association with corrected transposition of the great vessels, subpulmonary stenosis and a ventricular septal defect is presented. Surgical treatment of the subpulmonary stenosis and ventricular septal defect was carried out on cardiopulmonary bypass. The anatomic handicaps peculiar to corrected transposition which confront the surgeon in correcting these associated anomalies are discussed. The left Ebsteins anomaly discovered at autopsy was unsuspected during life and could not be recognized by external examination of the heart in this case. At postmortem examination the nonatrialized portion of the left ventricle appeared too small to maintain the systemic circulation. It is believed that this factor alone led to the patients death once the ventricular septal defect had been closed. Attention is again drawn to the common occurrence of abnormalities of the left atrioventricular valve in association with corrected transposition, left Ebsteins malformation being one of the rarer forms. It is recommended that digital exploration of the left atrium be carried out in all cases of corrected transposition selected for open cardiotomy procedures.

Chronic bronchitis and emphysema: Significance of the bacterial flora in the sputum

Abstract 1.1. This study was an effort to obtain data concerning the origin of bacteria in the sputum of patients with chronic bronchitis and emphysema. Of the sixteen patients who were bronchoscoped, eight had similar pathogenic flora in the sputum and bronchial aspirate. The remaining eight had pathogenic bacteria in the sputum but not in the bronchial aspirate. Possible reasons for this difference are discussed. 2.2. The data presented do not support the view that organisms in the sputum are derived from the nasopharynx during the process of expectoration. 3.3. The low incidence of pathogenic bacteria in the sputum of patients with bronchial asthma is important if confirmed in a larger series.

Anomalous Right Subclavian Artery Arising Proximal to a Postductal Thoracic Aortic Coarctation

Approximately 1% of patients with postductal thoracic aortic coarctation have an associated anomalous right subclavian artery. Previous reports indicated that the aberrant right subclavian vessel arose distal to the coarctation site. The case of a patient is presented in whom the anomalous right subclavian artery originated proximal to the postductal coarctation. We believe this to be among the first reports of this entity. The embryological development pathway and clinical implications of this congenital defect complex are discussed.

Right Heart Reconstruction Following Repair of Tetralogy of Fallot

Ten patients in whom tetralogy of Fallot had been repaired underwent late reconstruction of the outflow tract of the right ventricle because of poor hemodynamic results. The major hemodynamic problems that necessitated right ventricular (RV) outflow tract reconstruction were severe pulmonary insufficiency in 9 patients and pulmonary stenosis in 1. Impaired RV contractility and RV aneurysm were the most important factors prompting valve replacement for severe pulmonary insufficiency. Seven patients received a Hancock prosthesis and 3, an aortic homograft. Among the 7 patients who underwent postoperative cardiac catheterization, the surgical results were hemodynamically excellent in 2, good in 3, and unsatisfactory in 2. The management of pulmonary insufficiency in such patients is discussed.

Intraoperative Identification of the Conduction System in Repair of Endocardial Cushion Defect

Electrophysiological identification intraoperatively of the His-Purkinje system eliminates the complication of complete heart block consequent upon repair of endocardial cushion defect (ECD). Ten patients, 6 with complete ECD and 4 with incomplete ECD, underwent repair of the defect. None of the patients developed heart block. Slight variations were noted in the location of the His bundle in 9 patients, and a major deviation was found in 1 patient with incomplete ECD. The data support the use of intraoperative recordings as a necessary acconpaniment to the operative repair of ECD.