WELDON ET AL.

and there may be a normal axis on electrocardiogram. I t is the restricted volume of the cavity that makes this such a difficult problem. Failure to recognize these patients undoubtedly accounts for the discrepancy in results of pulmonary valvotomy reported from various centers.

Dr. Weldon presented an interesting case of a 5-year-old child who did not undergo palliative operation during infancy. I have some reservation about accepting this as a case of underdeveloped right ventricular cavity, for in my opinion it is rare for one of these patients to live five years without operation.

DR. CONRAD LAM (Detroit, Mich.): I should like to say a word in favor of the Glenn operation in these cases of hypoplastic right ventricle. The Glenn operation seems especially designed for this anomaly because with it, 40% of the blood goes directly to the left side of the heart without having to pass through the right side.

I would like to ask Dr. Weldon if he has considered using the Glenn opera- tion as a secondary procedure after a shunt done in the neonatal period. Four or five years later, these cyanotic children frequently need an additional pro- cedure; and rather than an additional shunt or perhaps even definitive correction, the Glenn operation should be considered. We have had 100% success in 7 patients by adding the Glenn operation to a previous palliative operation (shunt) in cases of tricuspid atresia, which is an extreme example of hypoplastic right heart.

DR. WELDON: First, in regard to Dr. Cooley’s doubt, I agree that the patient who had the total corrective procedure is a bit different from the ordinary patient one sees with pulmonary atresia and hypoplastic right ventricle. This particular defect, I think, has been well described in the report of Williams and his asso- ciates. I think the same defect was also described in the report by Berman and his colleagues in Los Angeles. I t consists of a large atrial septa1 defect: hypoplasia of the right ventricle, with the apex of the ventricle filled with extensive trabecula- tions; hypoplasia of the pulmonary annulus: and hypoplasia of the tricuspid annulus. It is not secondary hypertrophy as a result of the pulmonary stenosis; I am convinced of that. I think that this is probably even a rarer kind of hypo- plastic right ventricle than the kind associated with pulmonary atresia.

In regard to Glenn’s operation in the management of these patients, we have not employed it. This operation does make a great deal of physiological sense. I think it makes particularly good sense surgically when used the way Dr. Trusler has suggested. He recommends it as a second operation for the patient with a very hypoplastic right ventricle in whom an aortic pulmonary shunt had been per- formed in infancy. Glenn’s operation is not dependable in infants, but it can be reserved as an additional procedure in an older child.

NOTICE FROM THE EDITOR We wish to thank the many readers who responded to our request

for criticisms and suggestions. Although some of the proposed changes were not feasible at the present time, they did provide a number of ideas for the future direction of The Annals. We are incorporating those that are possible in the immediate future.

Constructive comments are always welcome. H. S.

502 THE ANNALS OF THORACIC SURGERY