known and possible number of patients on @blockers prior to testing and the irregular order of testing.” But the letter, signed In their article on scanning electron miby Jordan alone, is more notable for what croscopy of operatively excised severely it does not contain than for what it does regurgitant floppy mitral valves, Stein et contain. In fact, most of the information all stated that they have not found any necessary to clarify the original article studies of the surface microarchitecture was absent from the “clarification.” of floppy mitral valves shown by scanning There are also several statements in the electron microscopy. Such studies have letter that do not square with the facts as been carried out by Peter B. Baker, III, shown in the data books and other written Department of Pathology, Ohio State documentation and as reported by the University College of Medicine. Elegant NIH. scanning electron photomicrographs of For example, Jordan states that drug both normal and floppy mitral valves were withholding before exercise testing was “a published in the book entitled Mitral standard rule for testing in the laboratoValve Prolapse and the Mitral Valve Prory,” implying that the “error” in the artilapse Synd;ome by Boudoulas and Woo- cle had resulted from inadvertently aslev* from the same institution. The nhoto- suming that this was true in the study ggaphs nicely show surface tears on a flopgroup of patients. In fact, it was not a py mitral valve that can be a source of “standard rule” at all and the lack of drug platelet emboli. withholding was well known. Toward the Tsung 0. Cheng, MD end of the study in question the senior Washington,DC investigator sent out a memo to referring 9 August 1989 physicians stating that “since the policy 1. Stein PD, Wang CH, Riddle JM, Sabbah has not been formally established, many HN, Magilligan DJ, Hawkins ET. Scanning patients have come to the laboratory while electron microscopyof operatively excisedse- still under the influence of beta-blocking verely regurgitant floppy mitral valves. Am J agents.” He went on to request that referCardiol 1989:64:392-394. ring physicians try to discontinue them, if 1. BoudoulasH, Wooley CF. Mitral Valve Pro- possible, before testing. lapse and the Mitral Valve Prolapse Syndrome. The statement by Jordan that between Mount Kisco, New York: Fuiura, 1988: 292. 14 and 22 of the 54 patients received propranolol is inaccurate. Based on the data books plus information supplied by Cornell Medical Center to the NIH, someInsignificant Errors or where between 28 and 43 of the 54 paFatal Flaws tients either had been, or might have been, The letter to the editor by Jordan’ in the taking one of the proscribed medications, most of which were /3 blockers. October 1, 1988, issue describing 2 “erThe statement by Jordan that the studrors” in an article previously published in ies were not alternated (as had been the Journal2 raises several disturbing questions. To appreciate the issues in- claimed in the article) because “the refervolved it is necessary to understand some ring physicians required that the clinically of the background of the report and the mandated exercise testing be performed first” is disingenuous at best. The data controversy surrounding it. The manuscript was written in late books show that alternation of patients 1981 with Jordan (then a medical student tended to occur primarily during those peworking under the senior investigator) as riods when Jordan himself was in the labfirst author and me as one of the CO- oratory. During 1 prolonged period of his absence 27 of 29 patients were not alterauthors. The manuscript contained many methodologic claims that I believed to nated. With respect to the accuracy of the conrepresent deliberate misrepresentations of facts designed to make the research ap- clusions of the article Jordan’s letter is pear more rigorous, thorough and accu- even more unsatisfactory. There is no inrate than it really was. Although my name dication from his letter that the article’s was mercifully removed from the manu- validity might be in doubt as a result of the “unintentional errors” in the “2 statescript after my objections, the inaccuracies remained essentially unaltered and ments in the Methods section” that he the article was published in April 1983. writes about. Yet the NIH report raises Due to my concerns, an investigation by serious doubts about the reliability and the National Institutes of Health was be- validity of the conclusions. For example, the NIH report concluded gun in mid- 1982 and continued until September 1987 when a final disposition was that the lack of alternation of studies made. The final NIH report led to a num- “may have biased the results and it inappropriately enhanced the credibility of the ber of sanctions against the senior investireport.” gator, including the “recommendation” The NIH concluded that “the misstatethat a clarification of the article be issued. Jordan’s letter was presumably in re- ment in the manuscript about withholding sponse to that recommendation even of drugs certainly enhanced the credibilthough the senior investigator did not ity of the report inappropriately.” There is nothing in Jordan’s letter to share in the authorship of the letter. Jordan’s letter more or less fulfilled the suggest that the “blinding” alleged to have been performed during analysis of NIH’s formal “recommendation” that the imaging data might have been inadethe clarification “should include the

Scanning Electron Microscopy Floppy Mitral Valve

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quate. According to the NIH report “the inappropriate reference to blinded assessment inappropriately enhanced the credibility of the report.” In fact, the NIH report states that its investigation had “identified the use of procedures that are not adequate for creating research records, for conducting blinded angiographic readings, nor for pursuing and documenting the clinical suitability of patients.” And again, “a review of these publications does show a series of inexact and inadequate procedures.” There is a real need for correcting the scientific literature when such correction becomes necessary. But such a step requires commitment to the integrity of the literature and the courage to risk the embarassment it might cause. Such commitment and courage were lacking in Jordan’s “clarification.” Similarlv the senior investigator (as well, of course: as the other coauthors), in declining to cosign Jordan’s letter, failed to accept responsibility for even the watered-down version of events provided by Jordan. If these kinds of practices are to be considered acceptable, such “clarifications” will serve no useful purpose. Jerome

G. Jacobstein,

MD

Philadelphia, Pennsylvania 7 June 1989 1. Jordan LJ. Erratum. Am J Cardiol 1988: 62:841. 2. Jordan L, Borer J, Zullo M, Hayes D, Kubo S, Moses J, Carter J. Exercise versus cold temperature stimulation during radionuclide cineangiography: diagnostic accuracy in coronary artery disease. Am J Cardiol 1983:5/:10911097.

Left Ventricular-to-Right Atrial Shunt in Perimembranous Trabecular Ventricular Septal Defect with Aneurysmal Transformation We read the article by Helmcke et al’ reporting color Doppler findings in 58 patients with ventricular septal defect (VSD). According to the authors, a portion of the VSD jet moved into the right atrium through the septal leaflet of the tricuspid valve in 4 cases with perimembranous inlet VSD. Associated deficient septal leaflet was thus suspected in these patients. In our experiences, the left ventricular (LV)-to-right atria1 (RA) shunt can also be observed in patients with perimembranous trabecular VSD.2 The LV-RA shunt has been reported in patients with VSD following adherence of tricuspid valve to the septal margin, although the type of VSD was not specified.3.4 We reported the characteristic echocardiographic findings of perimembranous trabecular VSD with a newlv developed LV-RA shunt following the aneurysmal transformation in 7 cases4 This was best delineated in the apical 5-chamber view. Two such patients received open heart surgery, in which a perimembranous VSD extending to the trabecular portion beneath the anteroseptal commissure

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