E.: Pulmonic stenosis, ventricular septal defect, and right ventricular pressure above systemic level. Circulation 22: 405

pulmonic stenosis with an intact ventric-ular septum (designated as pulmonic stenosis) from pulmonic stenosis with a right-to-left shunt through a ventricular septal defect (te-tralogy of Fallot) by routine clinical, electro-cardiographic, and radiologic examination.1-3 If the diagnosis is still uncertain, it can as a rule be made by phonocardiography and car-diae catheterization,4 particularly if there is very severe pulmonic stenosis with an intact ventricular septum. Characteristically in se-vere pulmonic stenosis the right ventricular systolic pressure is much higher than in the systemic circulation and rises still higher after ectopic beats; the right ventricular pressure tracing is triangular; and right ventricular systole is prolonged so that on phonocardiog-raphy the second heart sound is widely split and the systolic murmur passes beyond aortic valve closure. Unfortunately these commonly accepted criteria may be unreliable. In this paper 10 patients are reported who, although meeting most or all of these criteria for the diagnosis of severe pulmonic stenosis (espe-cially with systolic pressures much higher in the right ventricle than in the systemic ar-teries), nevertheless were proved later to have an associated ventricular septal defect with a right-to-left shunt. An attempt is made to in-dicate how even under these circumstances a correct preoperative diagnosis may be made