LETTERS TO THE EDITOR PROPRANOLOL
THERAPY
DURING
PREGNANCY
AND
LACTATION
A letter from Drs. Levitan and Manionl concerning propranolol therapy during pregnancy and lactation is potentially quite important because of the lack of information on the excretion of propranolol in human milk. However, there appears to be a serious error that causes us to question the validity of their report. The authors assume the average amount of propranolol in the maternal blood to be 40 fig/ml and cite Coltart and Shand2 as their reference. The authors also report up to 60.8 fig/ml of propranolol in their patient. The amount of propranolol in the blood reported by Coltart and Shand, however, was actually 40 ng/ml, only l/1000 of that quoted. We therefore doubt that Levitan and Manion’s patient actually had a prdpranolol level of 60.8 wg/ml. Since the authors’ calculations for the daily amount of propranolol excreted in breast milk were based on a level 1,000 times the usual, the infant’s actual daily dose was probably only l/1000 of that calculated, or 15 to 20 wg of propranolol. This is clearly a trivial dose and is probably the reason that the infant experienced no effects from the drug in breast milk. Philip 0. Anderson, Pharm D Pharmacy Department University of California, San Diego San Diego, California Fred J. Salter, Pharm D Richmond, Virginia Reterences 1. Levftan AA, ManIOn JC: Propranolol therapy during pregnancy and lactation. Am J Cardiol32:2. 1973 2. Cottart DJ, Shand DG: Plasma propranolol levels in the quantitative assessment of beta adrenerqic blockade in man. Br f&d J 3731, 1970
REPLY
I have reviewed the data plus the assay technique relative to measurement of the propanolol levels in both blood and breast milk. Drs. Anderson and Salter are absolutely correct. There was an error in units in the reporting of the data out of the laboratory. The data should have been expressed in nanograms per milliliter instead of micrograms per milliliter. I very much appreciate their having brought this to my attention. Alexander A. Levitan, MD Minneapolis, Minnesota
ECHOCARDIOGRAM BACTERIAL
IN VEGETATIVE
AORTIC
ENDOCARDITIS
In Cases 2 and 3 of Martinez et al.’ reference is made to vegetations echocardiographically demonstrated on the anterior left coronary aortic cusp. Gramiak and Shah2 have demonstrated that the anterior echo within the aortic root arises from the right coronary cusp. Necropsy studies 2 and 7 days after echocardiographic examination in Cases 2 and
3, respectively, revealed in Case 2 several right coronary cusp perforations and cusp eversion and in Case 3 complete destruction of the right coronary cusp. Vegetations were found on the left coronary cusp in both cases. The right coronary cusp was obviously involved in both cases and could well have produced embolization in the period between the echocardiographic and necropsy examinations. Were emboli extensively searched for and found in these cases? It seems that the necropsy studies in this report do not justify labeling the anterior echo within the aortic root as the left coronary cusp. Lewis Sass& MD, FACC Department of Internal Medicine Southern California Permanente Medical Group Los Angeles, California References 1. MartinezEC
Lurch GE, Glles TD: Echocardiographic diagnosis of vegetative aortic bacterial endocarditis. Am J Cardiol34:845-849. 1974 2. Gramlak R, Shah PM: Cardiac uitrasonography. Radio1 Clin North Am 9469-490. 1971
REPLY
We are well aware of the controversy concerning identification of the anterior echo recorded from the aortic valve and indicated this in our paper. In the study cited by Sass& Gramiak and Shah consider the evidence to support the fact that the anterior echo of the aortic valve cusp originates from the right coronary cusp. Feigenbauml has indicated that it originates from the left coronary cusp. We certainly respect the opinion of Gramiak and Shah. Nevertheless, the observation that a prominent echo recorded from the aortic valve during life correlated with a large vegetation on the left coronary cusp is no less meaningful and supports the concept of Feigenbaum that the anterior echo originates from the left coronary cusp. The second paragraph of our discussion clearly reflects our interpretation of our data. George E. Burch, MD, FACC Thomas D. Giles, MD, FACC Department of Medicine Tulane University School of Medicine New Orleans, Louisiana Reference 1. Felgenbaum
H: Echocardiography.
Philadelph!a. Lea 8 Febiger.
1972. p 74
ADDENDUM
Weyman et a1.l have recently reported that the anterior echocardiographically recorded aortic leaflet is the right aortic leaflet. Apparently, the controversy mentioned by Drs. Burch and Giles has been resolved in favor of the anteriorly recorded aortic leaflet arising from the right leaflet. Lewis Sass& MD, FACC Reference 1. Weyman AE, Dlllon JC, Felgenbaum H, et al: Premature pulmonic valve opening following sinus of Valsalva aneurysm rupture into the right atrium. Circulation 51:556559, 1975
February 1976
The American Journal of CARDIOLOGY
Volume 37
325
THERAPY
DURING
PREGNANCY
AND
LACTATION
A letter from Drs. Levitan and Manionl concerning propranolol therapy during pregnancy and lactation is potentially quite important because of the lack of information on the excretion of propranolol in human milk. However, there appears to be a serious error that causes us to question the validity of their report. The authors assume the average amount of propranolol in the maternal blood to be 40 fig/ml and cite Coltart and Shand2 as their reference. The authors also report up to 60.8 fig/ml of propranolol in their patient. The amount of propranolol in the blood reported by Coltart and Shand, however, was actually 40 ng/ml, only l/1000 of that quoted. We therefore doubt that Levitan and Manion’s patient actually had a prdpranolol level of 60.8 wg/ml. Since the authors’ calculations for the daily amount of propranolol excreted in breast milk were based on a level 1,000 times the usual, the infant’s actual daily dose was probably only l/1000 of that calculated, or 15 to 20 wg of propranolol. This is clearly a trivial dose and is probably the reason that the infant experienced no effects from the drug in breast milk. Philip 0. Anderson, Pharm D Pharmacy Department University of California, San Diego San Diego, California Fred J. Salter, Pharm D Richmond, Virginia Reterences 1. Levftan AA, ManIOn JC: Propranolol therapy during pregnancy and lactation. Am J Cardiol32:2. 1973 2. Cottart DJ, Shand DG: Plasma propranolol levels in the quantitative assessment of beta adrenerqic blockade in man. Br f&d J 3731, 1970
REPLY
I have reviewed the data plus the assay technique relative to measurement of the propanolol levels in both blood and breast milk. Drs. Anderson and Salter are absolutely correct. There was an error in units in the reporting of the data out of the laboratory. The data should have been expressed in nanograms per milliliter instead of micrograms per milliliter. I very much appreciate their having brought this to my attention. Alexander A. Levitan, MD Minneapolis, Minnesota
ECHOCARDIOGRAM BACTERIAL
IN VEGETATIVE
AORTIC
ENDOCARDITIS
In Cases 2 and 3 of Martinez et al.’ reference is made to vegetations echocardiographically demonstrated on the anterior left coronary aortic cusp. Gramiak and Shah2 have demonstrated that the anterior echo within the aortic root arises from the right coronary cusp. Necropsy studies 2 and 7 days after echocardiographic examination in Cases 2 and
3, respectively, revealed in Case 2 several right coronary cusp perforations and cusp eversion and in Case 3 complete destruction of the right coronary cusp. Vegetations were found on the left coronary cusp in both cases. The right coronary cusp was obviously involved in both cases and could well have produced embolization in the period between the echocardiographic and necropsy examinations. Were emboli extensively searched for and found in these cases? It seems that the necropsy studies in this report do not justify labeling the anterior echo within the aortic root as the left coronary cusp. Lewis Sass& MD, FACC Department of Internal Medicine Southern California Permanente Medical Group Los Angeles, California References 1. MartinezEC
Lurch GE, Glles TD: Echocardiographic diagnosis of vegetative aortic bacterial endocarditis. Am J Cardiol34:845-849. 1974 2. Gramlak R, Shah PM: Cardiac uitrasonography. Radio1 Clin North Am 9469-490. 1971
REPLY
We are well aware of the controversy concerning identification of the anterior echo recorded from the aortic valve and indicated this in our paper. In the study cited by Sass& Gramiak and Shah consider the evidence to support the fact that the anterior echo of the aortic valve cusp originates from the right coronary cusp. Feigenbauml has indicated that it originates from the left coronary cusp. We certainly respect the opinion of Gramiak and Shah. Nevertheless, the observation that a prominent echo recorded from the aortic valve during life correlated with a large vegetation on the left coronary cusp is no less meaningful and supports the concept of Feigenbaum that the anterior echo originates from the left coronary cusp. The second paragraph of our discussion clearly reflects our interpretation of our data. George E. Burch, MD, FACC Thomas D. Giles, MD, FACC Department of Medicine Tulane University School of Medicine New Orleans, Louisiana Reference 1. Felgenbaum
H: Echocardiography.
Philadelph!a. Lea 8 Febiger.
1972. p 74
ADDENDUM
Weyman et a1.l have recently reported that the anterior echocardiographically recorded aortic leaflet is the right aortic leaflet. Apparently, the controversy mentioned by Drs. Burch and Giles has been resolved in favor of the anteriorly recorded aortic leaflet arising from the right leaflet. Lewis Sass& MD, FACC Reference 1. Weyman AE, Dlllon JC, Felgenbaum H, et al: Premature pulmonic valve opening following sinus of Valsalva aneurysm rupture into the right atrium. Circulation 51:556559, 1975
February 1976
The American Journal of CARDIOLOGY
Volume 37
325
