The present status of cardiac surgery.

The numerous reports appearing in current British, American and French journals testify to the interest aroused by recent advances in cardiac surgery. It may, therefore, be helpful to recall certain landmarks in its history and to review the present status of those procedures which have proved of value. Congenital Heart Disease Although the surgical treatment of pulmonary stenosis is now soundly established it is well to recall that until I944 these cases were of interest only to the morbid anatomist. Many types of congenital cardiac deformities had been described, but it was only when Helen Taussig realized that the essential abniormality in cyanotic children was a deficient blood flow from heart to lungs that therapeutic interest was aroused. With Taussig's support Blalock (I946) devised the operation of systemic-pulmonary anastomosis, since named after him. This increases pulmonary blood flow, alleviates the crippling disability and transforms the life of these pathetic children. This advance stimulated interest in the surgical treatment of heart disease and cardiologists began to assess the operability of an unsuspected backlog of thousands of similar cases. Congenital deformities account for 2.5 per cent. of heart disease. The principal abnormalities occur in the pulmonary outflow tract and include pure pulmonary stenosis and the tetralogy of Fallot. Untreated the prognosis is grave. In pure pulmonary stenosis the obstruction is nearly always at the valve, there is no ventricular septal defect, and cyanosis, if it occurs, is due to a patent foramen ovale. Right ventricular pressure is high and sudden right-sided heart failure a constant threat. Though the diagnosis of pure pulmonary stenosis is difficult clinically, it may be made on catheterization of the heart when the right ven-tricular pressure may be shown to be higher than the systemic pressure, or by angiocardiography when the overriding aorta and rapid ventricular emptying of the tetralogy are absent. Pulmonary valvotomy* through the right ventricle by the technique of Brock (I948) and Sellors (1948) is the treatment of choice. Systemic-pulmonary anas-tomosis is dangerous as it does nothing to relieve the strain on the right ventricle and adds to that on the left. In the more common tetralogy of Fallot the stenosis may be infundibular or valvular or occasionally both. The narrowing of the outflow tract and the ventricular septal defect diminish pulmonary blood flow and cyanosis is present to a varying degree. Diagnosis is relatively easy. Valvotomy relieves the valvular stenosis and the low infundibular …