Letters
Aortic
valve
to the Editor
disease
surgery
To the Editor: The Editorial, “Surgery for aortic valve disease” in the December, 1974, issue of the JOURNAL (AM. HEART J. 88683, 1974), was generally a thoughtful and conservatively stated position, which indicated that aortic valve replacement should not be done in the symptom-free patient, but that there appeared to be a “justifiable trend in that direction.” The line of reasoning was that truly successful surgery would have to occur prior to the development of irreversible myocardial damage. Against operation in asymptomatic patients with aortic stenosis is the limitation of what can be done surgically, short of valve replacement, and the short expectancy of prosthetic valves at present, to say nothing of the dangers of embolization and the requirement for anticoagulation. The number of youngsters who have congenital aortic valve anomalies is very large, and the great majority of these are asymptomatic and do not require surgery by standards of even the most wildly enthusiastic surgical proponents. For a youngster of 15, a “long-term” follow-up involves a great deal more than 10 years, with any luck at all. These patients do quite well in general, and probably form the group of patients out of which come the calcific aortic valves in the 40- to 60-year-old subjects. Given the many years of follow-up, and the rather stable presence of mild or moderate aortic stenosis, more objective grounds for surgical intervention must be present than fear of irreversible myocardial disease. I would wholeheartedly concur with Drs. Galyean, Suzuki, and Blake in accepting symptoms, particularly angina, as evidence for surgical intervention, but hemodynamic measurements are also necessary to avoid misinterpretation of subjective complaints. It was our feeling in 1965 that a valve area of 0.6 cm.” per square meter was a value below which surgery was indicated. We felt that peak pressures were not a reliable basis, and a mean ejection gradient of at least 45 mm. Hg is necessary to prove the necessity for surgical intervention. This relatively large reservoir of youngsters with mild to moderate aortic stenosis argues for a conservative approach, and that surgicai intervention should remain a carefully considered decision, with objective criteria, no matter how low the mortality rate becomes for putting in an artificial valve. Perhaps developments in non-invasive techniques such as the echocardiogram will permit recognition of the more marked degrees of left ventricular hypertrophy, hopefully before real dysfunction occum. It is unreasonable both to operate early, or to perform left heart catheterizations every year for 30 or 40 years. In the meantime, most of us believe that angina or left ventricular T-wave changes still stand as the reasonable indications for left heart catheterization, and possible surgery, if catheter data substantiate the severity. Warren G. Guntheroth, M.D. Professor of Pediatrics (Cardiology) School of Medicine Department of Pediatrics University of Washington Seattle, Wash. 98195
818
REFERENCE
1. Morgan, B. C., Guntheroth, W. G., Baum, D., and Merendino, K. A.: Reassessment of operative indication for moderate congenital aortic stenosis, J. Thorac. Cardiovasc. Surg. 49:150, 1965.
Reply To the Editor: We appreciate Dr. Guntheroth’s interest in our editorial and find no fundamental conflict between our observations and his. It seems to us that he, a pediatrician, is emphasizing the difficulty in knowing when to recommend cardiac catheterization in asymptomatic subjects and is pointing out that findings in the electrocardiogram may help. While it is not clear just what he means by “left ventricular T-wave changes,” we feel sure that he implies negativity of T in left precordial leads where the QRS is almost completely positive, and we know that he is aware of the limitations of the method, that the electrocardiogram may be normal in some patients with severe aortic stenosis. We concur with Dr. Guntheroth that a conservative approach to children with mild or moderate aortic stenosis is appropriate, and share his hope that non-invasive techniques may eventually permit an accurate assessment of not only the presence of left ventricular overload by whatever name but also the adequacy of compensatory mechanisms, and enable us to recognize their deterioration in time to be able to intervene appropriately. James R. Galyean, III, M. D. Assistant Professor of Medicine Division of Cardiovascular Diseases Department of Medicine University of Mississippi Medical Center Jackson, Miss. 39216
Jugular device
venous pressure gauge. A bedside to measure jugular venous pressure
To the Editor: Bedside measurement of jugular venous pressure (JVP) is an important step in the assessment of patients with congestive heart failure as well as of those with hypervolemia/ overhydration. The principle involved in the measurement of JVP was elucidated by Lewis,’ who emphasised that JVP is the vertical distance between the uppermost limit of the distended/pulsating external/internal jugular vein (UJV) and the sternal angle of Louis (SA). Thus JVP can be measured by placing a centimeter ruler vertically at SA and directing a straight edge, held at right angles to the ruler, towards the neck at UJV. However, the results could be fallacious if the ruler is not held exactly vertical and/or if the straight edge is not exactly horizontal; moreover, if the JVP is normal or only slightly raised, the clavicle often comes in the way of the straight edge, making the measurement somewhat difficult. A
June, 1975, Vol. 89, No. 6
Aortic
valve
to the Editor
disease
surgery
To the Editor: The Editorial, “Surgery for aortic valve disease” in the December, 1974, issue of the JOURNAL (AM. HEART J. 88683, 1974), was generally a thoughtful and conservatively stated position, which indicated that aortic valve replacement should not be done in the symptom-free patient, but that there appeared to be a “justifiable trend in that direction.” The line of reasoning was that truly successful surgery would have to occur prior to the development of irreversible myocardial damage. Against operation in asymptomatic patients with aortic stenosis is the limitation of what can be done surgically, short of valve replacement, and the short expectancy of prosthetic valves at present, to say nothing of the dangers of embolization and the requirement for anticoagulation. The number of youngsters who have congenital aortic valve anomalies is very large, and the great majority of these are asymptomatic and do not require surgery by standards of even the most wildly enthusiastic surgical proponents. For a youngster of 15, a “long-term” follow-up involves a great deal more than 10 years, with any luck at all. These patients do quite well in general, and probably form the group of patients out of which come the calcific aortic valves in the 40- to 60-year-old subjects. Given the many years of follow-up, and the rather stable presence of mild or moderate aortic stenosis, more objective grounds for surgical intervention must be present than fear of irreversible myocardial disease. I would wholeheartedly concur with Drs. Galyean, Suzuki, and Blake in accepting symptoms, particularly angina, as evidence for surgical intervention, but hemodynamic measurements are also necessary to avoid misinterpretation of subjective complaints. It was our feeling in 1965 that a valve area of 0.6 cm.” per square meter was a value below which surgery was indicated. We felt that peak pressures were not a reliable basis, and a mean ejection gradient of at least 45 mm. Hg is necessary to prove the necessity for surgical intervention. This relatively large reservoir of youngsters with mild to moderate aortic stenosis argues for a conservative approach, and that surgicai intervention should remain a carefully considered decision, with objective criteria, no matter how low the mortality rate becomes for putting in an artificial valve. Perhaps developments in non-invasive techniques such as the echocardiogram will permit recognition of the more marked degrees of left ventricular hypertrophy, hopefully before real dysfunction occum. It is unreasonable both to operate early, or to perform left heart catheterizations every year for 30 or 40 years. In the meantime, most of us believe that angina or left ventricular T-wave changes still stand as the reasonable indications for left heart catheterization, and possible surgery, if catheter data substantiate the severity. Warren G. Guntheroth, M.D. Professor of Pediatrics (Cardiology) School of Medicine Department of Pediatrics University of Washington Seattle, Wash. 98195
818
REFERENCE
1. Morgan, B. C., Guntheroth, W. G., Baum, D., and Merendino, K. A.: Reassessment of operative indication for moderate congenital aortic stenosis, J. Thorac. Cardiovasc. Surg. 49:150, 1965.
Reply To the Editor: We appreciate Dr. Guntheroth’s interest in our editorial and find no fundamental conflict between our observations and his. It seems to us that he, a pediatrician, is emphasizing the difficulty in knowing when to recommend cardiac catheterization in asymptomatic subjects and is pointing out that findings in the electrocardiogram may help. While it is not clear just what he means by “left ventricular T-wave changes,” we feel sure that he implies negativity of T in left precordial leads where the QRS is almost completely positive, and we know that he is aware of the limitations of the method, that the electrocardiogram may be normal in some patients with severe aortic stenosis. We concur with Dr. Guntheroth that a conservative approach to children with mild or moderate aortic stenosis is appropriate, and share his hope that non-invasive techniques may eventually permit an accurate assessment of not only the presence of left ventricular overload by whatever name but also the adequacy of compensatory mechanisms, and enable us to recognize their deterioration in time to be able to intervene appropriately. James R. Galyean, III, M. D. Assistant Professor of Medicine Division of Cardiovascular Diseases Department of Medicine University of Mississippi Medical Center Jackson, Miss. 39216
Jugular device
venous pressure gauge. A bedside to measure jugular venous pressure
To the Editor: Bedside measurement of jugular venous pressure (JVP) is an important step in the assessment of patients with congestive heart failure as well as of those with hypervolemia/ overhydration. The principle involved in the measurement of JVP was elucidated by Lewis,’ who emphasised that JVP is the vertical distance between the uppermost limit of the distended/pulsating external/internal jugular vein (UJV) and the sternal angle of Louis (SA). Thus JVP can be measured by placing a centimeter ruler vertically at SA and directing a straight edge, held at right angles to the ruler, towards the neck at UJV. However, the results could be fallacious if the ruler is not held exactly vertical and/or if the straight edge is not exactly horizontal; moreover, if the JVP is normal or only slightly raised, the clavicle often comes in the way of the straight edge, making the measurement somewhat difficult. A
June, 1975, Vol. 89, No. 6
