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The twins described in this case had no radiologic evidence of a congenital anomaly, despite exhaustive testing. The fact that the cardiac rhythms were synchronous was cause for concern, because synchronous heart rhythms in thoracopagus twins have been shown to be consistent with shared cardiac chambers. 2,3 An electrocardiogram demonstrating independent QRS complexes suggests isolated ventricles. We could not find any case in the literature where there was an isolated myocardial bridge that could be separated.Although the ability of individual myocytes to sustain an electrical potential and go through the cardiac cycle has been well described, the ability of shared myocardial tissue to propagate a rhythm between two individual hearts has not. The potential for heart block or other fatal arrhythmias was entertained, because we could not predict the electrophysiologic consequences of separating this tissue. Since the operation, the children have shown no cardiac abnormalities and have remained in sinus rhythm.

A case of giant bullous disease with pulmonary transmogrification is described in which the bulla was initially mistaken for a pneumothorax. This report reviews the possible pitfalls in the diagnosis of this rare histologic subtype of bullous emphysema, which has been described in only 8 patients. The patient course including successful surgical resection and management options are reviewed.Emphysema occurs most commonly in smokers and patients with α 1 -antitrypsin deficiency. A rare congenital form of giant bullous emphysema was described in 1979 and termed pulmonary placental transmogrification. 1 It is rare and has been described once in the surgical literature. 2 Clinical summary. The patient is a 39-year-old white woman who underwent a left modified radical mastectomy for ductal carcinoma in situ with immediate reconstruction with a saline implant. A preoperative chest x-ray film revealed a "hyperinflated right lung, with decreased vascular markings." At the time of subpectoral prosthetic implantation, the pleura was violated and a thoracostomy tube placed. A postoperative chest radiograph revealed good expansion on the left side and what was believed to be a right pneumothorax. A thoracostomy tube was placed in the right side of the chest. She was then referred for definitive management after the left pneumothorax resolved but the right-sided abnormality, which was, in reality, a giant bulla persisted (Fig 1 ). A computed tomographic scan revealed a giant right upper lobe bulla with partial right middle and lower lobe inflation (Fig 2). The mediastinal structures were shifted to the left, but the patient tolerated this well. She underwent video-assisted thoracoscopic surgery with successful staple resection of this giant bulla. On postoperative day 3 a small air leak had sealed. On postoperative day 4, however, she had a new, significant air leak that persisted and culminated in re-exploration on postoperative day 7. At thoracotomy, a very small, previously obscured bulla originating from the lower lobe was found to have a 2-mm hole. The bulla was stapled and a generous parietal pleurectomy was performed. Her subsequent recovery was uneventful and she was discharged 3 days later with a fully expanded right lung.

Chronic aortic dissections are complex lesions with a fairly predictable natural history depending on factors such as baseline aortic diameter, the degree of false lumen thrombosis, the presence of a persistent communication, an underlying connective tissue disorder, and the control of hypertension. Medical management with antihypertensive therapy including beta-blockers is the treatment of choice for all stable chronic aortic dissections. Repair is indicated in the case of complications: aortic rupture, malperfusion syndromes, symptomatic dissections, asymptomatic dissections becoming significantly aneurysmal or demonstrating a rapid growth rate. In this regard, serial imaging of the aorta is crucial to detect unstable lesions requiring surgery or an endovascular intervention. As endograft technologies improve endovascular approach may become the future standard of care.

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