echocardiogram said to demonstrate prolapse of the mitral valve is shown. Upon careful examination of this figure, I do not think that this demonstrates prolapse of the mitral valve. The portion of the mitral valve seen during systole apparently sits on top of the ventricular myocardium, and is seen to closely parallel the movement of this ventricular myocardium. At the point in late systole when the mitral valve is said to prolapse, both the mitral valve and the underlying ventricular

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... m are seen to move abruptly posteriorly, as pointed out also in the diagram accompanying the figure. This is not unexpected. As suggested by Feigenbaum,' it is usually best to record the prolapsing posterior leaflet at the junction between the posterior left ventricular wall and the posterior wall of the left atrium. In our experience, it has been absolutely necessary to have some portion of the left atrium into which the mitral valve prolapses appear on the echo, or the echocardiographic appearance of prolapse may be entirely missed. In addition, although not stated by the authors, it appears that their echocardiogram was done utilizing the polaroid technique for photographing the face of the oscilloscope on which the echocardiogram is displayed. We have also found that in difficult cases, where prolapse is not immediately evident, the use of a stripchart recorder can be very helpful in demonstrating this abnormality. The diagnosis of a ballooning posterior leaflet, confirmed in this case by both left ventricular angiography and postmortem examination, can indeed be quite difficult utilizing the less adequate polaroid technique. We concur that one would ideally wish to record the prolapsing posterior leaflet at the junction between the posterior left ventricular wall and the 780 posterior wall of the left atrium. At the time of examination we were forced to utilize the polaroid technique and therefore were unable to display satisfactorily a simultaneous portion of the left atrial wall. Because the posterior movement recorded during systole would be atypical in timing and direction for ventricular endocardium, we interpreted this as consistent with a ballooning posterior leaflet. The advent of strip chart recorders in the past one year at our institution, which were not available when this patient was studied, has made our accuracy for this and other diagnoses' more certain. Editorial on direct myocardial revascularization' is typical of the care, thoughtfulness and unusual modesty which shines through this outstanding surgeon's many recent reports of bypass surgery. It represents a sincere attempt to objectify operative results through careful preand postoperative evaluation. It is also symptomatic of the unfortunate state-of-the-art in evaluating the results of surgical as compared with nonsurgical therapies. Unlike pills and inject:ons, reasonable-appearing surgical procedures are widely applied just as soon as their technicalities appear to be worked out. We are then forced to sort out their indications entirely retrospectively, as in this instance, involving considerable untangling of data and the absence of acceptable control series. Few physicians doubt that coronary bypass should be of great value for many patients, but the traditional "trial and error" method has proved totally unacceptable in deciding whom it will benefit. Fortunately, determined demands by dissenters have finally resulted in prospective trials with randomized allocation of qualifying patients.2' 3,4 That this is not universally true is made clear by an Editorial5 fairly damning a report published nine months earlier of another form of cardiac surgerv for which there was no control series.6 Both this editorial and Dr. Bourassa's were necessarily post hoc efforts.