Download Stenotic Semilunar Valve in Persistent Truncus Arteriosus

Stenotic Semilunar Valve in Persistent
Truncus Arteriosus*
Marion K. Ledbetter,
M.D.; Rajendra
Jack L. Titus, M.D., and Jesse
Tandon,
E. Edwards,
M.D.;
M.D.,
F.C.C.P.
The clinical, hemodynamic, and pathologic findings in
truncus arteriosus arose exclusively from the right ven-
two newborn infants with persistent truncus arteriosus
tricle and was almost exclusively stenotic. A ventricular
and stenosis of the truncal valve are described. In one
septal defect was the only outlet for the left ventricle. In
case the anatomic features of the basic condition were
this case, mitral stenosis was also present and associated
classic, with a dysplastic semilunar valve which was main-
with a left-to-right shunt at the atrial level.
ly stenotic and also incompetent, while in the other the
W^ he valve of persistent truncus arteriosus is often
CASE REPORTS
r
dysplastic and incompetent
The
clinical,
hemodynamic,
1
but rarely stenotic.
and pathologic
find-
ings of a stenotic truncal valve were first described
in a case report by Burnell and associates in 1971
2
and again by Lee and associates in 1973. W e have
3
observed two examples of truncal valvular stenosis;
our case
1 was similar to that of Burnell et al,
z
and case 2 had some findings like that of Lee et al.
3
The purpose of this report is to present the clinical, hemodynamic, and necropsy findings of these
two cases. Both had been
admitted
shortly
after
birth (within a three-week period) to the intensive
care nursery of St. Mary's Hospital, Madison, Wis.
We
could not find any common features
in
the
gestational histories to indicate pathogenesis. However, case 1 had a strong family history of congenital heart disease.
Following initial management of congestive failure,
both babies were subjected to cardiac cathe-
terization to establish the diagnosis. Thereafter, they
were
transferred
Hospitals
further
and
to
the
the
Mayo
consideration
University
Clinic,
regarding
of
Minnesota
respectively,
the
feasibility
for
of
operation.
" F r o m the Section of Pediatric Cardiology, St. Mary's Hospital Medical Center, Madison, W i s . ; the Departments of
Pathology, United Hospitals-Miller Division, St. Paul, a n d
the University of Minnesota, Minneapolis; and the Section of
Pathologic Anatomy, Mayo Clinic, Rochester, Minn.
This study was supported by Public Health Service research
grant 5 R O l H L 0 5 6 9 4 and research training grant 5 T O l
H L 0 5 5 7 0 from the National Heart and L u n g Institute.
Manuscript received June 5 ; revision accepted August 4 .
Reprint
requests:
Dr. Edwards.
United
Hospitals
(Miller
Division), 125 West College
Avenue, St. Paul
55102
182
CASE 1
Clinical
Features.
T h e boy was the product of an uncomplicated 42-week gestation in a 27-year-old primigravida woman. Delivery was uncomplicated, and the infant's
birth weight was 4 , 0 2 6 gm ( 8 lb, 14 o z ) . Resuscitative measures were not required, and the Apgar score was 9 at one
minute. However, at 3 0 minutes the skin had become dusky;
and tachycardia, tachypnea, and a loud continuous murmur
were present.
Cardiac consultation at 7 5 minutes revealed mild cyanosis
of the lips while the infant breathed high concentrations of
oxygen. T h e respiratory' rate was 70/min, with intercostal
retractions. A coarse thrill was palpable at the apex and
left axilla. Both heart sounds were loud. A grade 3/6 systolic murmur was followed by a single second sound. A
loud high-pitched murmur persisted through diastole, was
loudest at the cardiac base and third left interspace, and
sounded more like a ductus arteriosus than aortic insufficiency. A loud diastolic flow murmur was heard at the apex.
T h e brachial and femoral pulses were normal. T h e hepatic
edge was palpated 3 cm below the right costal margin.
An electrocardiogram on the day of hirth showed sinus
rhythm with a rate of 1 5 0 beats per minute. T h e mean
frontal-plane Q R S axis was + 9 0 . T h e tracing was within
the normal range for the newborn. Thoracic roentgenograms
showed a shift of the mediastinum and the heart to the left,
with prominent pulmonary vascular markings. T h e cardiac
size and the pulmonary congestion increased over the next
three days.
Administration of digoxin and ethacrynic acid was begun
at 12 hours of a g e without appreciable response. Cardiac
catheterization was performed at 2 0 hours of age. T h e catheter could b e advanced into the right pulmonary artery from
the ascending aorta, suggesting the presence of truncus arteriosus. A withdrawal tracing from the right pulmonary artery to the truncus arteriosus and the right ventricle showed
a stepwise increase in pressures ( T a b l e 1 ) . T h e left ventricle
LEDBETTER ET AL
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CHEST, 6 9 : 2 , FEBRUARY, 1 9 7 6
T a b l e 1 — C a r d i a c Catheterization
Data from
Caseg 1 and
Case 1 (Age, 2 0 hr)
((xygen
Site
Saturation ( % ) * *
Superior vena eava
Inferior vena eava
Right atrium
Left atrium
R i g h t ventricle
68
65
65
93
64
Left ventricle
Aorta
Right pulmonary artery
83
69
Case 2 (Age. 6 days)
Pressure (mm H g ) f
,
A
S/D
7/1
9/-1
126/-9
(ed = 10)
130/-5
(ed = 10)
72/32
51/29
*A11 venous pressures were " a " waves.
* ' S a t u r a t i o n s were obtained while breathing air.
^
Mean
8/3
6/2
2*
Oxygen
Saturation ( % ) * *
Pressure (mm H g ) f
SI)
Mean
4
3
2
4
60
69
78
96
79
16/4
15/2
15/2
19/7
134/-6J
(ed = 18)
8
7
7
13
47
91
58/38J
45
40
f S / D , Systolie/diastolic; and ed, end-diastolic.
^Simultaneous pressures.
was catheterized from the right ventricle via a ventricular
septal defect. Oxygen saturations revealed evidence of bidirectional shunting of blood. O n the basis> of preferential
streaming, there was a significant difference in the oxygen
saturations of the blood between the right pulmonary artery
and the aorta; the former was 6 9 percent and the latter 8 3
percent saturated. An aortogram ( F i g l a ) showed filling of
both pulmonary arteries from the base of the arterial trunk,
as well as a right aortic arch, confirming the diagnosis of
persistent truncus arteriosus. T h e r e was regurgitation of moderate degree through the semilunar valve. A left ventriculogram ( F i g l b ) showed a jet of contrast medium through
the truncal valve, confirming the stenosis indicated by withdrawal pressure tracings. T h e contrast medium cleared
promptly from the heart, indicating that semilunar valvular
insufficiency was not severe. Despite vigorous anticongestive measures, the infant died at six days of age.
T h e family history was interesting in that the infant's father
had tetralogy of Fallot with pulmonary atresia, a diagnosis
which had been established by cardiac catheterization; also,
a paternal aunt had a ventricular septal defect which had
been repaired surgically.
Pathologic
Features.
T h e cardiac and visceral configuration was that of situs solitus. T h e heart was moderately en-
larged. Only one great vessel, measuring 12 mm in diameter,
arose above the ventricles. T h e pulmonary trunk came off
from the left side of this vessel, a situation seen in type 1
persistent truncus arteriosus. T h e pulmonary trunk divided
immediately into the left and right pulmonary arteries with
normal course and distribution ( F i g 2 ) .
T h e truncal valve was bicuspid and dysplastic. Both of the
thickened cusps showed further incomplete division, suggesting a quadricuspid valve. T h e diameter of the lumen through
the valve was 6 mm ( F i g 3 ) . T h e first set of branches from
the truncus arteriosus were the two coronary arteries. T h e y
c a m e off behind the opposite, incompletely divided cusps
anteriorly and posteriorly. T h e distribution of the artery
arising anteriorly was like that of the right coronary artery,
while that of the other was like the left coronary artery.
T h e next branch from the truncus was the pulmonary trunk,
6 mm in diameter, which arose 5 mm above the truncal
valve. T h e aortic arch was right-sided. T h e branching from
the arch had a mirror-image distribution ( F i g 2 a ) . T h e
ductus arteriosus was absent. T h e systemic and pulmonary
venous returns were normal, and the coronary sinus opened
normally into the right atrium. A 10 X 3 mm atrial septal
defect resulting from a valvular incompetent foramen ovale
was present at the fossa ovalis. T h e tricuspid and mitral
F I G U R E 1 ( c a s e 1 ) . a (left).
Catheter is in dilated truncus arteriosus. Right aortic arch is present.
Large pulmonary arteries arise from base of common trunk, b. ( r i g h t ) . Injection during systole
into base of left ventricle. Jet of contrast material streams through stenotic truncal valve.
CHEST, 69: 2, FEBRUARY,
1976
PERSISTENT TRUNCUS ARTERIOSUS
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183
FIGUHE 2 ( c a s e 1 ) . a ( l e f t ) . Truncus arteriosus has been sectioned above truncal valve to display
short pulmonary trunk from which, in turn, right ( R P ) and left ( L P ) pulmonary arteries arise.
Aorta ( A o ) proceeds upward as right aortic arch which lies to right of trachea ( T r ) . b
(right).
Right ventricle ( R V ) and truncal valve. Immediately beneath valve is characteristic ventricular
septal defect. ( D ) .
CASE 2
valves were normal and led into hypertrophied and dilated
right and left ventricles, respectively. T h e right ventricular
wall measured 5 mm and the left ventricular wall 6 mm
in thickness.
T h e truncus arteriosus was the outlet for both ventricles.
It overrode the ventricular septum, arising approximately
two-thirds above the right and one-third above the left ventricle ( F i g 2 ) . T h e ventricular septal defect, 10 mm in
diameter, was in the superior aspect of the septum and immediately below the origin of the truncus arteriosus. On the
right ventricular aspect the poorly developed parietal limb of
the crista supraventricularis separated the truncal valve from
the tricuspid valve. Mitral-truncal valvular continuity was
maintained.
was heard at the cardiac apex. T h e second sound was split
with a wide interval unchanged during the respiratory cycle.
T h e liver projected 3 cm below the right costal margin.
Brachial and femoral arterial pulses were equal and slightly
bounding in contour.
A roentgenogram of the thorax revealed cardiomegaly
with a globular configuration of the heart and increased
pulmonary vascular markings. T h e E C G showed a short P-R
interval, negative delta waves in lead V ] , and wide Q R S
complexes with a duration of 0.10 second, indicating the
type B Wolfl-Parkinson-White syndrome. This pattern persisted unchanged. T h e infant was digitalized but remained
lethargic, nursed pm)rly, and continued in a state of congestive failure.
Cardiac catheterization at six days of age ( T a b l e 1 ) re-
Clinical
Features.
T h e patient was a 3 , 1 7 5 gm ( 7 l b )
girl. T h e 42-week gestation of the 23-year-old gravida
2 mother was complicated only by cystitis during the sixtii
month, for which sulfonamide compounds were administered.
Resuscitation of the infant was not necessary. T h e Apgar
score at one minute was 8 and at five minutes was 10. Slight
duskiness of the skin and a grade 2/6 systolic murmur were
noted at 3 0 minutes. A grade 4/6 systolic murmur and a
diastolic murmur were noted on the third day after birth. On
the fourth day of life, the infant was transferred to the intensive care nursery of St. Mary's Hospital Medical Center.
Examination on admission at four days of age revealed
edema involving the face and eyelids. T h e infant was mildly
cyanotic and somnolent but was easily aroused. T h e breath
sounds were clear with shallow excursions at 60/min. T h e
cardiac rate was 155 beats per minute, and the sounds were
accentuated. T h e first sound was followed by a grade 4/6
systolic murmur and thrill most intense at the fourth left
interspace. T h e murmur was widely transmitted over the
anterior wall of the thorax, and a middiastolic flow murmur
184
F I C U R E 3. Unopened truncal valve viewed from above. Valve
is markedly dysplastic and stenotic (case 1 ) .
LEDBETTER ET AL
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CHEST, 6 9 : 2, FEBRUARY, 1976
minimally regurgitant, with only a small amount of contrast
medium entering the heart after the truncal injection. A left
atriogram revealed a small left atrium with a large shunt
into the dilated right atrium. A small left ventricle and the
truncus arteriosus were visualized following flow through
the mitral valve. T h e diagnosis after cardiac catheterization
was type 1 or 2 truncus arteriosus with atrial and ventricular
septal defects and truncal valvular stenosis.
T h e infant remained in severe congestive cardiac failure;
therapy with digitalis and diuretics was continued. T h e cardiac size increased progressively, and left pleural effusion
developed. W h e n quiet and breathing air, the infant showed
nearly normal cutaneous color, but mild cyanosis occurred
when she cried. T h e infant died at 24 days of age.
Pathologic
Features.
T h e essential pathologic features were
as follows. Arising from the right ventricle was a single
arterial vessel. This divided into a short pulmonary trunk,
from which the right and left pulmonary arteries and the
aorta arose. T h e aortic arch was left-sided. T h e truncal valve
was quadrieuspid and stenotic. T h e mitral valve was hypoplastic and stenotic. T h e left ventricular chamber was also
hypoplastic, and its only outlet was a narrow muscular-type
ventricular septal defect. T h u s , there was no mitral-truncal
valvular continuity. T h e chambers of the right atrium and
ventricle were enlarged, and the valve of the foramen ovale
was herniated toward the right atrium.
F I G U R E 4. Systolic pressure of right ventricle measured twice
corresponding systolic pressure of truncus arteriosus. High
pressure flush (arrow)
indicates that truncal pulse recorded
through No. 4 French catheter is minimally damped. E l e c t r o cardiogram reveals delta waves of preventricular excitation
(case 2 ) .
vealed elevated systemic venous pressures and a left-to-right
shunt at the atrial level. T h e right ventricular systolic pressure measured more than twice the aortic systolic pressure
( F i g 4 ) . T h e left ventricle could not he catheterized. Selective cineangiograms revealed large pulmonary arteries which
originated from the base of the truncus arteriosus above a
narrow root ( F i g 5 ) . T h e truncal valve was narrowed and
DISCUSSION
A diagnosis of persistent truncus arteriosus requires that the systemic, pulmonary, and coronary
circulations arise from a common trunk which
emerges from the heart. The truncus arteriosus
usually arises more from the right ventricle than
from the left ventricle. Origin from only the right
ventricle is a rare form of the anomaly previously
reported by Lampertico (case 4 3 ) , but without
the semilunar valvular stenosis. Dysplasia of the
semilunar valves is common in truncus arteriosus.
4
1
F I G U R E 5. (case 2 ) . a ( l e f t ) . Catheter entered truncus arteriosus retrogradely from femoral artery
and left aortic arch. Dilated pulmonary arteries arise from common vessel, b (right).
Dilated
and heavily trabeculated right ventricle gives origin to dilated common trunk above narrowed
root. Stenotic valve domes into vessel.
CHEST, 6 9 : 2, FEBRUARY,
1976
PERSISTENT TRUNCUS ARTERIOSUS
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185
Gelband and associates presented autopsy data
from 12 babies less than six months of age, seven
of whom had deformed and incompetent truncal
valves. In these latter seven, refractory cardiac failure had been present.
Van Praagh and Van Praagh reported the pathologic findings in one case with probable truncal
valvular stenosis. Victorica and associates reported
catheterization data on two patients with significant
ventricular-truncal valvular gradients, but without
pathologic data. Victorica et al presented phonocardiographic evidence that the second heart sound
may be split (as in our case 2) when only one
semilunar valve is present. Victorica (personal
communication) described the autopsy of another
newborn infant with a quadricuspid stenotic truncal valve. Two of the cusps were completely fused.
Tandon and associates reported systolic ejection
murmurs in eight of 19 cases of persistent truncus
arteriosus, but catheterization data revealed no important pressure gradients between either ventricle,
on one hand, and the truncus arteriosus, on the
other.
As mentioned before, the hemodynamic and
pathologic features of our case 1 were similar to
the case of truncal valvular stenosis reported by
Burnell and associates, with the exceptions that
their infant had diminished peripheral pulses,
whereas ours did not; and their infant had a left
aortic arch, and our case 1 had a right arch. Except for the stenotic semilunar valves, the case of
Burnell et al and our case 1 may be considered
classic examples of persistent truncus arteriosus in
that the common trunk overrode a large ventricular
septal defect, and truncal-mitral valvular fibrous
continuity was preserved.
Also, as previously mentioned, the hemodynamics and cardiac anatomy of our case 2 had similarities to the case of Lee and associates. The persistent truncus arose only from the right ventricle;
therefore, egress from the left ventricle was only
through the ventricular septal defect into the right
ventricle. Venous pressure and right ventricular
systolic and end-diastolic pressures were severelyelevated. The main differences were that our case
2 had a stenotic mitral valve, a small left ventricle,
and a narrow ventricular septal defect, whereas the
case of Lee et aP had a large ventricular septal defect and a dilated left ventricle.
Becker and associates performed gross and histologic studies on the semilunar valves from 14
cases of truncus arteriosus. All had abnormal deposits of mucoid connective tissue on the valve
cusps, with progression to gross nodularity in
nine. The process had extended onto the commis5
6
7
7
8
2
2
3
sures in four cases. Though none of these valves
appeared stenotic, these workers postulated that
greater degrees of this dysplastic process might
cause stenosis. When the semilunar valve is severely dysplastic in truncus arteriosus, insufficiency
is nearly always the only abnormality of hemodynamic importance. Congestive heart failure usually causes the death of these infants by two months
of age.
5
Progression to stenosis can occur, and stenosis
was the dominant lesion involving the valves of
both babies in our report. Case i, in whom there
was associated insufficiency of the valve, had normal peripheral pulses. The pulses of case 2 were
bounding in contour, although the degree of semilunar valvular incompetence was barely appreciable
by aortography.
A stenotic semilunar valve may be incompetent
to the extent that it cannot close in diastole. A
severely stenotic valve may be minimally incompetent, since the orifice is small. The character of
peripheral pulses is not entirely dependent on the
anatomy of the semilunar valve. In truncus arteriosus, there is free runoff of the blood into the pulmonary arteries, as occurs in the patent ductus
arteriosus, and the pulses may have a wide contour
even when the truncus valve is competent. Conversely, congestive cardiac failure associated with
decreased systemic perfusion causes lowering of
the blood pressure and diminishes pulses.
The rapid onset of congestive cardiac failure
in our case 1 and the short fulminating course of
both patients despite decongestive measures attest
to the clinical importance of these truncal valvular
lesions. The relatively high oxygen consumption of
postnatal life may have contributed to the development of congestive cardiac failure shortly after
birth rather than prenatally. The volume overload
of a large pulmonary flow was added at birth to the
prenatally sustained pressure overload.
We considered surgical palliation of these two infants by valvotomy and banding of the pulmonary
arteries. However, it seemed unlikely that integrity
of the truncal valve would have been obtained.
With the origin of the truncus from the right ventricle in case 2, the stenotic mitral valve and the
narrow ventricular septal defect would have obviated a satisfactory operative result.
REFERENCES
1
186
1 Becker A E , Becker MJ, Edwards J E : Pathology of semilunar valve in persistent truncus arteriosus. J Thorac Cardiovasc Surg 6 2 : 1 6 - 2 6 , 1971
2 Burnell RH, McEnery G, Miller G A H : Truncal valve
stenosis. Br Heart J 3 3 : 4 2 3 - 4 2 4 , 1971
3 Lee M J , Bellon E M , Liebnian J , et al: Truncal valve steno-
LEDBETTER ET AL
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CHEST, 69: 2, FEBRUARY, 1 9 7 6
sis. Am Heart J 8 5 : 3 9 7 - 4 0 0 , 1 9 7 3
4 Lampertico P : Persistent truncus arteriosus communis: Review of the literature and presentation of 4 9 cases of true
truncus arteriosus and 18 examples of related conditions.
Folia Hered Pathol 1 4 ( s u p p l 4 ) : 1-134, 1 9 6 4
5 Gelband H, Van Meter S, Gersony W M : Truncal valve
abnormalities in infants with persistent truncus arteriosus:
A clinicopathological study. Circulation 4 5 : 3 9 7 - 4 0 3 , 1972
6 Van Praagh R, Van Praagh S: T h e anatomy of common
aorticopulmonary trunk (truncus arteriosus communis)
and its embryologic complications: A study of 57 necropsy
cases. Am J Cardiol 1 6 : 4 0 6 - 4 2 5 , 1 9 6 5
7 Victorica B E , Krovetz L J , Elliott L P , et a l : Persistent
truncus arteriosus in infancy: A study of 14 cases. Am
Heart J 7 7 : 1 3 - 2 5 , 1 9 6 9
8 Tandon R, Hauck A J , Nadas A S : Persistent truncus arteriosus; A clinical, hemodynamic, and autopsy study of nineteen cases. Circulation 2 8 : 1 0 5 0 - 1 0 6 0 , 1 9 6 3
The Larynx
F e w o r a t o r s of f a m e , p r e a c h e r s of g r e a t p o p u l a r i t y ,
brilliant a c t o r s a n d a c t r e s s e s of t h e t h e a t e r , o r o u t s t a n d i n g vocal artists of c o n c e r t s halls a n d o p e r a h o u s e s h a v e
b e e n a w a r e or a p p r e c i a t i v e of t h e i n t r i c a t e f u n c t i o n a l
m a r v e l s of t h e i r v o c a l a p p a r a t u s . T h r o u g h e o n s , p h o n a tion has b e c o m e a u n i v e r s a l m a n n e r of h u m a n c o m m u n i c a t i o n . I t is b r o u g h t a b o u t b y t h e r e l e a s e o f puffs o f
air ( a i r p u l s e s ) t h r o u g h t h e glottis. T h e n u m b e r o f
these puffs, d e t e r m i n e d by t h e resilience, tension and
v i b r a t i o n of t h e v o c a l c o r d s , g o v e r n s t h e p i t c h o f t h e
v o i c e w h e n v o c a l i z i n g . It w a s P y t h a g o r a s
(540-500
B C ) , the Greek philosopher and mathematician, who
first a s c e r t a i n e d t h a t t h e p i t c h o f s o u n d is p r e d i c a t e d o n
t h e l e n g t h of t h e v i b r a t i n g c o r d ; also, h e w a s t h e disc o v e r e r of t h e m e c h a n i s m of t o n a l h a r m o n y . I n c o n v e r s a tional s p e e c h t h e f r e q u e n c y of v i b r a t i o n s of t h e v o c a l
c o r d s varies f r o m 8 0 c y c l e s p e r s e c o n d in m e n to 4 0 0
c y c l e s p e r s e c o n d in w o m e n . T h r o u g h o u t r e c o r d e d h i s tory s i n g i n g h a s d e v e l o p e d i n t o a u b i q u i t o u s m e a n s for
e x p r e s s i n g p e r s o n a l j o y or s o r r o w , r e l i g i o u s d e v o t i o n ,
patriotic dedication, melancholic yearning, and boisterous m a r t i a l c o u r a g e . T h e c l i m a x o f artistic s i n g i n g is
best exemplified by the phonatory calisthenics of colora t u r a s o p r a n o s , b y v o c a l e x h i b i t i o n in m u s i c d r a m a s , a n d
by the b e l c a n t o v i r t u o s i t y of s i n g e r s in roles i d e n t i f i e d
with m e l o d i o u s , l y r i c a l , r o m a n t i c a r i a s . T h e s t r u c t u r e
o f t h e l a r y n x is b a s e d on n i n e c a r t i l a g e s ( t h r e e s i n g l e
and three p a i r e d ) : t h e epiglottis, thyroid, cricoid, aryte n o i d s , c o r n i c u l a t e s of S a n t o r i n i a n d t h e c u n e i f o r m s o f
W r i s b e r g . T h e v o c a l c o r d s a r e r e a d i l y v i s u a l i z e d b y ind i r e c t l a r y n g o s c o p y . T h e l a t t e r w a s i n v e n t e d b y a singing t e a c h e r M a n u e l G a r c i a ( 1 8 0 5 - 1 9 0 6 ) , b o m in M a d r i d ,
t e a c h i n g in L o n d o n a n d P a r i s . T h e i n t r i n s i c l a r y n g e a l
muscles modulate phonatory changes of the vocal cords.
T h e f u n c t i o n a r y role o f t h e s e m u s c l e s is well s u m m a r i z e d
in o n e of t h e m e d i c a l c l a s s i c ( G r a y , H : A n a t o m y o f t h e
Human Body, 29th ed, American ed b y Goss, C M
P h i l a d e l p h i a , L e a and F e b i g e r , 1 9 7 4 ) . T h e p o s t e r i o r
cricoarytenoids separate the vocal cords and thus open
t h e glottis. T h e l a t t e r is c l o s e d b y t h e l a t e r a l c r i c o a r y t -
CHEST, 69: 2, FEBRUARY, 1 9 7 6
e n o i d s . T h e u n p a i r e d a r y t e n o i d c l o s e s t h e glottis, e s p e c i a l l y a t its b a c k p a r t . T h e c r i c o t h y r o i d s t i g h t e n a n d
e l o n g a t e t h e v o c a l c o r d s a n d c l o s e t h e glottis. T h e m a i n
u s e of t h e t h y r o a r y t e n o i d s is to s h o r t e n a n d relax t h e
v o c a l c o r d s . " T h e i r l a t e r a l p o r t i o n s n a r r o w t h e riga
glottidis by bringing t h e vocal cords together. Certain
m i n u t e fibers of t h e v o c a l i s division, d e s i g n a t e d as a r y v o c a l i s m u s c l e s a r e c o n s i d e r e d b y S t r o n g ( ' 3 5 ) to b e
c h i e f l y r e s p o n s i b l e f o r t h e c o n t r o l of p i t c h , t h r o u g h t h e i r
a b i l i t y to r e g u l a t e t h e l e n g t h of t h e v i b r a t i n g p a r t of t h e
v o c a l f o l d s . " I t is t r u l y a m a z i n g t o w i t n e s s t h e f a c i l i t y
w i t h w h i c h t r a i n e d s i n g e r s a r e a b l e to p r o d u c e m e l l i f l u o u s , e n c h a n t i n g m e l o d i e s , or s o n o r o u s e x p r e s s i o n o f
dramatic emotions b y maneuvering the laryngeal struct u r e s as if t o u c h i n g t h e k e y s o f a p i a n o or t h e strings
of a Stradivarius, with virtuoso dexterity. Jackson, C
a n d Jackson, C L (Diseases of the Nose, T h r o a t and
E a r , 2 n d e d , P h i l a d e l p h i a , S a u n d e r s , J 9 5 9 ) offer t h e
f o l l o w i n g p e r t i n e n t c o m m e n t s . " T h e t r a i n e d s o p r a n o , in
producing high notes, unconsciously
increases
the
t r a c h e a l a i r p r e s s u r e c o o r d i n a t e l y as s h e firms t h e c o r d a l
e d g e s a n d s h o r t e n s t h e s u p r a g l o t t i c air c o l u m n b y r a i s i n g t h e larynx a n d d i a m e t r i c a l l y d i m i n i s h e s t h e oral a n d
p h a r y n g e a l air c o l u m n b y f o r c i n g u p w a r d all tissues
a t t a c h e d t o t h e h y o i d b o n e . T h e lips a r e t r a i n e d to b e
kept separated widely. Additionally the trained soprano
narrows the ventricle a n d p h a r y n x . " T h u s , transposition
o f l i f e l e s s m u s i c a l n o t e s i n t o b e a u t i f u l s i n g i n g is t h e
a d m i r a b l e r e s u l t of t h e i n t e r p l a y o f t h e c e n t r a l n e r v o u s
system, t h e diaphragm, thoracic and relatively miniat u r e m u s c l e s of t h e l a r y n x . T h e v o i c e o f c o l o r a t u r a sop r a n o , L u c r e z i a A g u j a r i of 1 8 t h c e n t u r y I t a l y , r e a c h e d
u p t o C in alt, ie a w h o l e o c t a v e a b o v e h i g h C , c o r r e s p o n d i n g to a v o c a l c o r d v i b r a t i o n o f 2 0 4 8 c p s as
c o m p a r e d to 1 4 0 8 c p s o f t h e v o c a l c o r d s o f o t h e r sop r a n o s . W h a t a h e a v e n l y r e v e l a t i o n it m u s t h a v e b e e n
to M o z a r t w h o h a d listened to a recital given b y
L u c r e z i a A g u j a r i in P a r m a , I t a l y .
Andrew L. Banyai,
PERSISTENT TRUNCUS ARTERIOSUS
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