necessary if regurgitation is
severe.
Currently, mitral valve repair is the preferred form of surgical treatment
for MVP with severe mitral valve regurgitation. In general, mitral valve repair is better than mitral valve replacement for the following reasons: (1) operative mortality with repair is about half that with valve replace¬ ment; (2) long-term survival with re¬ pair is greater than that with valve replacement; (3) thromboembolism is about one fourth as frequent after re¬ pair than after valve replacement, with the most striking differences re¬ ported when replacement with me¬ chanical valves was compared with repair; (4) postoperative left ventric¬ ular function is preserved after repair but is compromised after replacement; (5) although some studies reported a rate of second operations after repair that was, on average, twice that as¬ sociated with replacement, this rate discrepancy was not evident in all studies; and (6) postoperative infec¬ tive endocarditis seems to be less fre¬ quent after repair than after valve re¬ placement.7 Furthermore, mitral valve repair is ideally suited for treatment of mitral régurgitation due to MVP, much more so than for mitral régur¬ gitation due to rheumatic fever.8 TSUNG O. CHENG, MD The George Washington
University Division of Cardiology 2150 Pennsylvania Ave NW Washington, DC 20037
1. Allen HD. Mitral valve prolapse: back to the basics. AJDC. 1991;145:1095-1096. 2. Barlow JB, Cheng TO. Mitral valve billowing and prolapse. In: Cheng TO, ed. The International Textbook of Cardiology. Elmsford, NY: Pergamon Press Inc; 1987:497-524. 3. Cheng TO. Mitral valve prolapse. Dis Mon. 1987;33:481-534. 4. Cheng TO. Should antibiotic prophylaxis be recommended for all patients with mitral valve prolapse? Am J Cardiol. 1991;68:564. 5. Cheng TO. Office cardiology: controversies in the management of mitral valve prolapse. Mod Med. 1991;59:48-56. 6. Cheng TO. Mitral valve prolapse: a mul-
tidisciplinary
Hosp Physician. Krayenbuchl HP. Surgery for mitral regurgitation: repair versus valve replacement. Eur Heart J. 1986;7:638-643. 8. Cheng TO. Mitral valve prolapse: when is it serious? Postgrad Med. 1990;88:93-100. 1991;27:25-37.
concern.
7.
ment is still indicated when repair is not possible. I chose the extreme example of replacement to point out that MVP is not always the benign
tains the segment of the larger group that is more likely to use drugs. The article also states that "In the past 6 years, while lifetime use of cannabis by American high school se¬ niors declined from 55% to 41%, it appears to have increased in the Neth¬ erlands. First, as I mentioned above, I am not sure how much of an in¬ crease there was from the figures mentioned. Second, the author's in¬ tention was to show that legalizing drug use leads to increased use. Did he notice that the (illegal) use of can¬ nabis in the United States was much greater than the (legal) use of can¬ nabis in the Netherlands? I appreciate that Schwartz is con¬ cerned about this issue and wishes to convince us of the validity of his con¬ clusions, but also ask that he pay more attention to detail. KENNETH R. KILTY, MD Case Western Reserve
condition that we sometimes lead patients to believe. I thank Dr Cheng for his comments. HUGH D. ALLEN, MD Division of Cardiology
Children's
"
Hospital
700 Children's Dr Columbus, OH 43205 1. Allen HD. Mitral valve prolapse: back to the basics. AJDC. 1991;145:1095-1096.
Drug Abuse in
the Netherlands Sir. \p=m-\TheOctober19 1 issue of AJDC contained an article by Schwartz1 regarding drug abuse. While I do not wish to debate the issues involved in the article, I would like to discuss the statistics used in one paragraph in
University
Department of Pediatrics
particular.
The article states, "In the Netherlands, results of a drug use survey published more than 6 years ago noted that only 4% of adolescents of all ages ever tried cannabis (marijuana). A more recent survey of AMsterdam residents revealed that 32% of boys and 24% of girls between the ages of 16 and 19 years had ever tried cannabis." We are to conclude from this that cannabis use has increased drastically, presumably due to legalization of the drug. I question whether a study conducted "in the Netherlands," which I presume involved the whole country (the article does not say), can be compared with a study conducted in Amsterdam, a large (and rather notorious) city. The first percentage was for adolescents of all ages; the second was for those aged 16 to 19 years. I do not think it is legitimate to compare these two age groups be¬ cause the latter is a subset of the former and because the higher per¬ centage of drug use in the latter group probably reflects the fact that it con-
Cannabis Use
MetroHealth Saint Luke's
Medical Center 11311 Shaker Blvd Cleveland, OH 44104 1.
In Reply.
rect. In my brief article, I did not men-
tion that mitral valve repair is indeed preferred to mitral valve replacement
whenever possible, although replace-
Legalization of drugs of pediatrician. AJDC. 1991;145:
\p=m-\Iampleased to answer the
raised by Dr Kilty about the results of recent surveys on drug use by Dutch high school students and their relevance to drug use trends in the United States. After the publication of my article on legalization of drugs of abuse, 1 the director of the Alcohol, Drugs, and Tobacco branch of the Ministry of Welfare, Health, and Cultural Affairs of the Netherlands sent me the 1991 English translation of the results of the fourth and most recent National Youth Health Care Survey.2 Survey data were collected between 1988 and 1989 at 45 Youth Health Care Centers across the country. A total of 8019 youths aged 10 years and older were surveyed. Most were enrolled in secondary
questions
by Students in the Netherlands, 1988* Age
In
Reply. \p=m-\DrCheng's comments regarding my editorial on MVP1 are cor-
Schwartz RH.
abuse and the 1153-1158.
Lifetime use Used cannabis in last 12 mo Used cannabis in last 30 d "Values are percentages of students
surveyed.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Pittsburgh User on 06/03/2015
Age
15-16 y
17-19 y
10.8 8.5
17.3
5.2
4.5
9.1
severe.
Currently, mitral valve repair is the preferred form of surgical treatment
for MVP with severe mitral valve regurgitation. In general, mitral valve repair is better than mitral valve replacement for the following reasons: (1) operative mortality with repair is about half that with valve replace¬ ment; (2) long-term survival with re¬ pair is greater than that with valve replacement; (3) thromboembolism is about one fourth as frequent after re¬ pair than after valve replacement, with the most striking differences re¬ ported when replacement with me¬ chanical valves was compared with repair; (4) postoperative left ventric¬ ular function is preserved after repair but is compromised after replacement; (5) although some studies reported a rate of second operations after repair that was, on average, twice that as¬ sociated with replacement, this rate discrepancy was not evident in all studies; and (6) postoperative infec¬ tive endocarditis seems to be less fre¬ quent after repair than after valve re¬ placement.7 Furthermore, mitral valve repair is ideally suited for treatment of mitral régurgitation due to MVP, much more so than for mitral régur¬ gitation due to rheumatic fever.8 TSUNG O. CHENG, MD The George Washington
University Division of Cardiology 2150 Pennsylvania Ave NW Washington, DC 20037
1. Allen HD. Mitral valve prolapse: back to the basics. AJDC. 1991;145:1095-1096. 2. Barlow JB, Cheng TO. Mitral valve billowing and prolapse. In: Cheng TO, ed. The International Textbook of Cardiology. Elmsford, NY: Pergamon Press Inc; 1987:497-524. 3. Cheng TO. Mitral valve prolapse. Dis Mon. 1987;33:481-534. 4. Cheng TO. Should antibiotic prophylaxis be recommended for all patients with mitral valve prolapse? Am J Cardiol. 1991;68:564. 5. Cheng TO. Office cardiology: controversies in the management of mitral valve prolapse. Mod Med. 1991;59:48-56. 6. Cheng TO. Mitral valve prolapse: a mul-
tidisciplinary
Hosp Physician. Krayenbuchl HP. Surgery for mitral regurgitation: repair versus valve replacement. Eur Heart J. 1986;7:638-643. 8. Cheng TO. Mitral valve prolapse: when is it serious? Postgrad Med. 1990;88:93-100. 1991;27:25-37.
concern.
7.
ment is still indicated when repair is not possible. I chose the extreme example of replacement to point out that MVP is not always the benign
tains the segment of the larger group that is more likely to use drugs. The article also states that "In the past 6 years, while lifetime use of cannabis by American high school se¬ niors declined from 55% to 41%, it appears to have increased in the Neth¬ erlands. First, as I mentioned above, I am not sure how much of an in¬ crease there was from the figures mentioned. Second, the author's in¬ tention was to show that legalizing drug use leads to increased use. Did he notice that the (illegal) use of can¬ nabis in the United States was much greater than the (legal) use of can¬ nabis in the Netherlands? I appreciate that Schwartz is con¬ cerned about this issue and wishes to convince us of the validity of his con¬ clusions, but also ask that he pay more attention to detail. KENNETH R. KILTY, MD Case Western Reserve
condition that we sometimes lead patients to believe. I thank Dr Cheng for his comments. HUGH D. ALLEN, MD Division of Cardiology
Children's
"
Hospital
700 Children's Dr Columbus, OH 43205 1. Allen HD. Mitral valve prolapse: back to the basics. AJDC. 1991;145:1095-1096.
Drug Abuse in
the Netherlands Sir. \p=m-\TheOctober19 1 issue of AJDC contained an article by Schwartz1 regarding drug abuse. While I do not wish to debate the issues involved in the article, I would like to discuss the statistics used in one paragraph in
University
Department of Pediatrics
particular.
The article states, "In the Netherlands, results of a drug use survey published more than 6 years ago noted that only 4% of adolescents of all ages ever tried cannabis (marijuana). A more recent survey of AMsterdam residents revealed that 32% of boys and 24% of girls between the ages of 16 and 19 years had ever tried cannabis." We are to conclude from this that cannabis use has increased drastically, presumably due to legalization of the drug. I question whether a study conducted "in the Netherlands," which I presume involved the whole country (the article does not say), can be compared with a study conducted in Amsterdam, a large (and rather notorious) city. The first percentage was for adolescents of all ages; the second was for those aged 16 to 19 years. I do not think it is legitimate to compare these two age groups be¬ cause the latter is a subset of the former and because the higher per¬ centage of drug use in the latter group probably reflects the fact that it con-
Cannabis Use
MetroHealth Saint Luke's
Medical Center 11311 Shaker Blvd Cleveland, OH 44104 1.
In Reply.
rect. In my brief article, I did not men-
tion that mitral valve repair is indeed preferred to mitral valve replacement
whenever possible, although replace-
Legalization of drugs of pediatrician. AJDC. 1991;145:
\p=m-\Iampleased to answer the
raised by Dr Kilty about the results of recent surveys on drug use by Dutch high school students and their relevance to drug use trends in the United States. After the publication of my article on legalization of drugs of abuse, 1 the director of the Alcohol, Drugs, and Tobacco branch of the Ministry of Welfare, Health, and Cultural Affairs of the Netherlands sent me the 1991 English translation of the results of the fourth and most recent National Youth Health Care Survey.2 Survey data were collected between 1988 and 1989 at 45 Youth Health Care Centers across the country. A total of 8019 youths aged 10 years and older were surveyed. Most were enrolled in secondary
questions
by Students in the Netherlands, 1988* Age
In
Reply. \p=m-\DrCheng's comments regarding my editorial on MVP1 are cor-
Schwartz RH.
abuse and the 1153-1158.
Lifetime use Used cannabis in last 12 mo Used cannabis in last 30 d "Values are percentages of students
surveyed.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Pittsburgh User on 06/03/2015
Age
15-16 y
17-19 y
10.8 8.5
17.3
5.2
4.5
9.1
