LETTERS TO THE EDITOR
reliability of plain left ventriculography as one of the better tools for the evaluation of left ventricular function in patients with ischemic heart disease. I have no criticism for a well conducted and extremely useful study by this excellent group of investigators. Furthermore, I would have considered it perfectly proper, for the sake of this investigation, that a number of consenting patients be studied on successive days in order to obtain the two needed sets of information. What disturbs me is a statement indicating that “patients in stable conditions underwent elective diagnostic cardiac catheterization and coronary arteriography on successive days in two laboratories, the usual practice at this institution.” (Italics By Dr. Gensini.) If this is the usual practice in a highly respected institution, such as the University of Oregon Medical School, what next? Should a patient in a less advanced laboratory expect to have his right coronary artery studied on Monday, the left on Tuesday, have angiography on Wednesday and the right and left heart catheterization on Thursday and Friday? Should we take left oblique views only on the odd days and reserve the right oblique views for the even days? A complete diagnostic study, inclusive of right and left heart catheterization, cardiac output, left ventriculography in two views, coronary arteriography in multiple views, with pressure measurements both before and after stress and vasodilators, can often be accomplished in less than 60 minutes from “skin to skin,” using a single cutdown procedure. The simpler combination of left heart catheterization, left ventriculography and coronary arteriography is usually carried out in 30 minutes or less and is considered a standard operating procedure in many laboratories, including our own. A serious breakdown in administrative policy or unexplainable divisions of responsibility or both must be at work whenever a patient, in order to obtain the same set of information, must be “invaded” twice in two different laboratories. I am a cardiologist and naturally I believe that the study of the heart is most appropriately performed by a well trained cardiologist. I have nothing against delegating that responsibility to someone primarily trained in another specialty, provided (1) his or her training in invasive cardiovascular techniques is the same as the one that a cardiologist would have to acquire in order to be qualified, and (2) there is no other qualified cardiologist willing or able to take on this responsibility. I am, however, profoundly disturbed by “usual practices” such as these and I hope that they will be voluntarily corrected, wherever they may exist. Goffredo G. Gensini, MD, FACC St. Joseph’s Hospital Health Center Syracuse, New York Reference 1. MCAnufty JH, Kremkau EL, Rosch J, et al: Spontaneous changes on left ventricular function between sequential studies. Am J Cardiol 3423-26.1974
REPLY A proper evaluation of the left ventricle should consider its overall systolic function and wall motion in addition to its diastolic properties.’ A word of caution against visual evaluation of left ventricular function from angiograms is appropriate because such assessments have a significant error rate.2 For these reasons, several parameters should be measured to evaluate left ventricular function adequately.
410
September 1975
The American Journal of CARDIOLOGY
At our institution complete hemodynamic evaluation and coronary angiography are often performed on separate days. Many patients undergoing such evaluations do not have coronary artery disease as their primary problem. This approach has allowed us to obtain complete studies without increasing the overall morbidity or mortality. In fact, we wish to emphasize the very low overall complication rate of our studies.“-g None of the patients described in our recent study had any complication. Thromboembolic episodes are the most frequent of the major complications of arterial studies. They are probably related to the length of time the catheter and wires are in the artery, the number of catheter exchanges and the technique used.lOrl l Studies on separate days decrease both the length of time any one catheter is in the arterial system and the number of catheter exchanges in any one study. The required additional arterial puncture for a dual study has not increased morbidity or difficulties with subsequent restudies. Our practice has allowed us to obtain thorough evaluations of cardiac function and of the coronary arterial system without subjecting patients to an increased risk. When possible, a complete evaluation with one study is preferable. However, in patients needing invasive studies, what is of primary importance is to obtain with consistency complete, reliable and accurate information at low risk. John H. McAnulty, MD Josef Rbsch, MD Shahbudin H. Rahimtoola. MD University of Oregon Medical School Portland, Oregon References 1 Rahlmtoola SH,Brlstow JD: The problem of assessment of left ventricular performance in coronary artery disease. Chest 65:460-461. 1974 2. Chsltman BR, Brislow JD. DeMots H, et al: Subjective vs objective assessment of left ventricular function. Chest 66:320, 1974 3. Green OS, McKlnnon CM, Riisch J, et al: Complications of selective percutaneous transfemoral coronary arleriography and their prevention. (A review of 445 consecutive examinations). Circulation 45: 552-557, 1972 4. Brlstow JD, Kioster FE, Herr R, et al: Cardiac catheterization studies after cornbined tricuspid, mttral and aortic valve replacement. Circulation 34:437-447. 1966 5. Trenouth RS, R&h J, Chsflman qR, et aI: Coronary angiography in the critically ill patient. In preparation 6 R&h J. DoMoi~ H. Antonovlc R, et al: Coronary angiography in Ml main coronary arterv disease. Am J Roentwnol 121:563-590. 1974 7 Cw&rative Study on Car& Catheterization (Braunwald E. Swan HJC. ed). New York, American Heal Association Monograph 36, 1966 6. RIsch J. Judklns MP, Green OS, el al: Aortocoronary venous bypass grafts-angiographic study of 64 cases. Radiology 102567-573. 1972 9. Ktoster FE, tirtstow JD, Seaman ii Cardiac catheterization during anticoagulant therapy. Am J Cardiot 261675-676. 1971 10 Adams DF, Fraser DE. Abrams HL: The complications of coronary arteriography Circutatiin 46:609-616. 1973 1 I. Judkfns MP. Gander MP: Prevention of complications of coronary arteriography Circuhtion 49:599-602. 1974
LIFE EXPECTANCY
AND MARATHON RUNNING
Dr. McIntosh correctly identifies the factors affecting the life expectancy of the American adult by calling for a “change in life styles.” ’ Because of the absence of fatal coronary heart disease among marathon runners,2 their life style is under study by the American Medical Joggers Association (AMJA). Distance running is being used in rehabilitation centers in Toronto and Honolulu. Several patients have trained up to the 42 km run after recovering from myocardial infarction, Problems in motivation have been partially solved by changing the emphasis from “patient” to “athlete” in the early stages of rehabilitation. Even during the closely supervised walking stages the patient has his eye on the December AMJA Honolulu Marathon. He trains with team-
Volume 36
LEllERS TO THE EDITOR
mates who are at the same level of fitness. Their coach is a cardiologist. AMJA pathologists expect not only a decrease in the incidence of coronary heart disease, but also, because of the teetotaling life style, fewer cases of cirrhosis, carcinoma of the lung, emphysema and generalized arteriosclerosis. Such programs may give us the increase in life expectancy of which McIntosh speaks. Thomas J. Bassler, MD Centinela Valley Hospital Inglewood, Calif. References
Cardiol 34: 127,
1. McIntosh HD: President’s page: life expectancy. Am J 2. Bssskr TJ: Lonpdistance runners. Science 182:113. 1973
1974
REPLY Intuitively, I believe that a well planned jogging program is important as both a prophylactic and a rehabilitative measure. Yet I believe that the data that prove this hunch correct are not yet available. I hope that the role of exercise in the treatment and prevention of coronary artery disease will be clarified soon. I hope, too, that Dr. Bassler will not continue to refer to AMJA pathologists who “expect not only a decrease in the incidence of coronary heart disease; but because of the teetotaling life style, they also expect to see fewer cases of cirrhosis, carcinoma of the lung, emphysema and generalized arteriosclerosis.” I hope that the pathologic data that become available to the American Medical Joggers Association will be examined by pathologists without preconceived ideas. Whether or not jogging increases life expectancy and reduces the progression of coronary artery disease, I, for one, can attest to the fact that it improves the quality of life. I do not believe, however, that one has to be a marathon runner to enjoy the benefits of reconditioning or to remain in good physical condition. I cannot emphasize strongly enough that the middle-aged, obese, smoking, sedentary male should not embark on a self-designed exercise program. He should have a careful physical examination with stress testing to be sure that if he does have ischemic heart disease that he is well aware of the limits to which he can exert without developing the process. Finally, Dr. Bassler’s enthusiasm is gratifying and I am sure infectious. I hope that he will always separate intuition from facts and so inform his listeners. Henry D. McIntosh, MD, FACC Department of Medicine The Methodist Hospital Houston, Texas
ACUPUNCTURE
ANESTHESIA FOR OPEN HEART SURGERY-l
I read with great interest Dr. Katz’s account of acupuncture anesthesia for open heart surgery. I too was a doubting Thomas about the much acclaimed wonders performed by our Chinese colleagues using acupuncture anesthesia in heart surgery until May 1972 when I visited the People’s Republic of China and observed several closed mitral commissurotomies performed under acupuncture anesthesia and July 1973 when I returned there to witness several open heart operations performed under acupuncture anes-
thesia. It was only after I had seen with my own eyes, as Dr. Katz has with his, that I became convinced that indeed it was, is and will be possible to do open heart operations using the technique of total cardiopulmonary bypass under acupuncture anesthesia. Dr. Katz’s account of operative repair of a ventricular septal defect in a youngster under acupuncture anesthesia is identical to what I saw being successfully accomplished in the same hospital and by the same surgical team, many members of which were my former schoolmates and classmates. For documentary purposes, I had the entire operation filmed through the courtesy of the Shanghai Branch of the Chinese Medical Association. More than 100 open heart operations have been performed under acupuncture anesthesia in that hospital since its first on April 19,1972, with a success rate of over 90 percent. The types of congenital heart disease so treated included ventricular septal defect, atria1 septal defect, pulmonary stenosis, trilogy of Fallot, tetralogy of Fallot and ruptured aortic sinus of Valsalva with ventricular septal defect. The youngest patient was 10 years of age and the longest period of extracorporeal circulation was 121 minutes. My Chinese colleagues neither considered acupuncture anesthesia to be a panacea for all open heart operations nor claimed perfection with this technique. Three “castles” or hurdles still remain in acupuncture anesthesia: incomplete relief of painful sensations during closure of median sternotomy, incomplete muscular relaxation during abdominal operations and uncomfortable sensation during mesenteric traction of gut handling. However, my Chinese colleagues are determined to lick these problems. Physicians in the western world tend to be somewhat critical of happenings that cannot be explained on a “scientific” basis. In fact, some even called acupuncture anesthesia a form of hypnosis. Such an attitude reflects ignorance and mulishness. I suggest to some of my American colleagues that we keep our mouths closed but our eyes open for further progress and development emanating from the medical horizons in the People’s Republic of China. Tsung 0. Cheng. MD, FACC Division of Cardiology Department of Medicine The George Washington University Medical Center Washington, D. C. Reference 1. Katz AM:
Acupuncture anesthesia for open heart surSery. A C~SB report. Am J Cardial 34:250-253. 1974
ACUPUNCTURE
ANESTHESIA-II
Medical journals should publish reports of clinical studies of methods that seem unlikely to be successful by our previous experience; there would be no progress otherwise. But this report of Dr. Katz is, in the language of the courtroom, hearsay evidence. Katz was not the physician in charge; he was not the surgeon; his closest contact to the patient was observation in the operating room. There is no evidence that he examined the patient beyond his observations in the operating theater. I doubt that you would publish a case report submitted by an observer, however interested, whose evidence consisted of the material presented here.
September 1975
Reuben Berman, MD Editor Minnesota
The American Journal of CARDIOLOGY
Medicine
Volume 36
411
reliability of plain left ventriculography as one of the better tools for the evaluation of left ventricular function in patients with ischemic heart disease. I have no criticism for a well conducted and extremely useful study by this excellent group of investigators. Furthermore, I would have considered it perfectly proper, for the sake of this investigation, that a number of consenting patients be studied on successive days in order to obtain the two needed sets of information. What disturbs me is a statement indicating that “patients in stable conditions underwent elective diagnostic cardiac catheterization and coronary arteriography on successive days in two laboratories, the usual practice at this institution.” (Italics By Dr. Gensini.) If this is the usual practice in a highly respected institution, such as the University of Oregon Medical School, what next? Should a patient in a less advanced laboratory expect to have his right coronary artery studied on Monday, the left on Tuesday, have angiography on Wednesday and the right and left heart catheterization on Thursday and Friday? Should we take left oblique views only on the odd days and reserve the right oblique views for the even days? A complete diagnostic study, inclusive of right and left heart catheterization, cardiac output, left ventriculography in two views, coronary arteriography in multiple views, with pressure measurements both before and after stress and vasodilators, can often be accomplished in less than 60 minutes from “skin to skin,” using a single cutdown procedure. The simpler combination of left heart catheterization, left ventriculography and coronary arteriography is usually carried out in 30 minutes or less and is considered a standard operating procedure in many laboratories, including our own. A serious breakdown in administrative policy or unexplainable divisions of responsibility or both must be at work whenever a patient, in order to obtain the same set of information, must be “invaded” twice in two different laboratories. I am a cardiologist and naturally I believe that the study of the heart is most appropriately performed by a well trained cardiologist. I have nothing against delegating that responsibility to someone primarily trained in another specialty, provided (1) his or her training in invasive cardiovascular techniques is the same as the one that a cardiologist would have to acquire in order to be qualified, and (2) there is no other qualified cardiologist willing or able to take on this responsibility. I am, however, profoundly disturbed by “usual practices” such as these and I hope that they will be voluntarily corrected, wherever they may exist. Goffredo G. Gensini, MD, FACC St. Joseph’s Hospital Health Center Syracuse, New York Reference 1. MCAnufty JH, Kremkau EL, Rosch J, et al: Spontaneous changes on left ventricular function between sequential studies. Am J Cardiol 3423-26.1974
REPLY A proper evaluation of the left ventricle should consider its overall systolic function and wall motion in addition to its diastolic properties.’ A word of caution against visual evaluation of left ventricular function from angiograms is appropriate because such assessments have a significant error rate.2 For these reasons, several parameters should be measured to evaluate left ventricular function adequately.
410
September 1975
The American Journal of CARDIOLOGY
At our institution complete hemodynamic evaluation and coronary angiography are often performed on separate days. Many patients undergoing such evaluations do not have coronary artery disease as their primary problem. This approach has allowed us to obtain complete studies without increasing the overall morbidity or mortality. In fact, we wish to emphasize the very low overall complication rate of our studies.“-g None of the patients described in our recent study had any complication. Thromboembolic episodes are the most frequent of the major complications of arterial studies. They are probably related to the length of time the catheter and wires are in the artery, the number of catheter exchanges and the technique used.lOrl l Studies on separate days decrease both the length of time any one catheter is in the arterial system and the number of catheter exchanges in any one study. The required additional arterial puncture for a dual study has not increased morbidity or difficulties with subsequent restudies. Our practice has allowed us to obtain thorough evaluations of cardiac function and of the coronary arterial system without subjecting patients to an increased risk. When possible, a complete evaluation with one study is preferable. However, in patients needing invasive studies, what is of primary importance is to obtain with consistency complete, reliable and accurate information at low risk. John H. McAnulty, MD Josef Rbsch, MD Shahbudin H. Rahimtoola. MD University of Oregon Medical School Portland, Oregon References 1 Rahlmtoola SH,Brlstow JD: The problem of assessment of left ventricular performance in coronary artery disease. Chest 65:460-461. 1974 2. Chsltman BR, Brislow JD. DeMots H, et al: Subjective vs objective assessment of left ventricular function. Chest 66:320, 1974 3. Green OS, McKlnnon CM, Riisch J, et al: Complications of selective percutaneous transfemoral coronary arleriography and their prevention. (A review of 445 consecutive examinations). Circulation 45: 552-557, 1972 4. Brlstow JD, Kioster FE, Herr R, et al: Cardiac catheterization studies after cornbined tricuspid, mttral and aortic valve replacement. Circulation 34:437-447. 1966 5. Trenouth RS, R&h J, Chsflman qR, et aI: Coronary angiography in the critically ill patient. In preparation 6 R&h J. DoMoi~ H. Antonovlc R, et al: Coronary angiography in Ml main coronary arterv disease. Am J Roentwnol 121:563-590. 1974 7 Cw&rative Study on Car& Catheterization (Braunwald E. Swan HJC. ed). New York, American Heal Association Monograph 36, 1966 6. RIsch J. Judklns MP, Green OS, el al: Aortocoronary venous bypass grafts-angiographic study of 64 cases. Radiology 102567-573. 1972 9. Ktoster FE, tirtstow JD, Seaman ii Cardiac catheterization during anticoagulant therapy. Am J Cardiot 261675-676. 1971 10 Adams DF, Fraser DE. Abrams HL: The complications of coronary arteriography Circutatiin 46:609-616. 1973 1 I. Judkfns MP. Gander MP: Prevention of complications of coronary arteriography Circuhtion 49:599-602. 1974
LIFE EXPECTANCY
AND MARATHON RUNNING
Dr. McIntosh correctly identifies the factors affecting the life expectancy of the American adult by calling for a “change in life styles.” ’ Because of the absence of fatal coronary heart disease among marathon runners,2 their life style is under study by the American Medical Joggers Association (AMJA). Distance running is being used in rehabilitation centers in Toronto and Honolulu. Several patients have trained up to the 42 km run after recovering from myocardial infarction, Problems in motivation have been partially solved by changing the emphasis from “patient” to “athlete” in the early stages of rehabilitation. Even during the closely supervised walking stages the patient has his eye on the December AMJA Honolulu Marathon. He trains with team-
Volume 36
LEllERS TO THE EDITOR
mates who are at the same level of fitness. Their coach is a cardiologist. AMJA pathologists expect not only a decrease in the incidence of coronary heart disease, but also, because of the teetotaling life style, fewer cases of cirrhosis, carcinoma of the lung, emphysema and generalized arteriosclerosis. Such programs may give us the increase in life expectancy of which McIntosh speaks. Thomas J. Bassler, MD Centinela Valley Hospital Inglewood, Calif. References
Cardiol 34: 127,
1. McIntosh HD: President’s page: life expectancy. Am J 2. Bssskr TJ: Lonpdistance runners. Science 182:113. 1973
1974
REPLY Intuitively, I believe that a well planned jogging program is important as both a prophylactic and a rehabilitative measure. Yet I believe that the data that prove this hunch correct are not yet available. I hope that the role of exercise in the treatment and prevention of coronary artery disease will be clarified soon. I hope, too, that Dr. Bassler will not continue to refer to AMJA pathologists who “expect not only a decrease in the incidence of coronary heart disease; but because of the teetotaling life style, they also expect to see fewer cases of cirrhosis, carcinoma of the lung, emphysema and generalized arteriosclerosis.” I hope that the pathologic data that become available to the American Medical Joggers Association will be examined by pathologists without preconceived ideas. Whether or not jogging increases life expectancy and reduces the progression of coronary artery disease, I, for one, can attest to the fact that it improves the quality of life. I do not believe, however, that one has to be a marathon runner to enjoy the benefits of reconditioning or to remain in good physical condition. I cannot emphasize strongly enough that the middle-aged, obese, smoking, sedentary male should not embark on a self-designed exercise program. He should have a careful physical examination with stress testing to be sure that if he does have ischemic heart disease that he is well aware of the limits to which he can exert without developing the process. Finally, Dr. Bassler’s enthusiasm is gratifying and I am sure infectious. I hope that he will always separate intuition from facts and so inform his listeners. Henry D. McIntosh, MD, FACC Department of Medicine The Methodist Hospital Houston, Texas
ACUPUNCTURE
ANESTHESIA FOR OPEN HEART SURGERY-l
I read with great interest Dr. Katz’s account of acupuncture anesthesia for open heart surgery. I too was a doubting Thomas about the much acclaimed wonders performed by our Chinese colleagues using acupuncture anesthesia in heart surgery until May 1972 when I visited the People’s Republic of China and observed several closed mitral commissurotomies performed under acupuncture anesthesia and July 1973 when I returned there to witness several open heart operations performed under acupuncture anes-
thesia. It was only after I had seen with my own eyes, as Dr. Katz has with his, that I became convinced that indeed it was, is and will be possible to do open heart operations using the technique of total cardiopulmonary bypass under acupuncture anesthesia. Dr. Katz’s account of operative repair of a ventricular septal defect in a youngster under acupuncture anesthesia is identical to what I saw being successfully accomplished in the same hospital and by the same surgical team, many members of which were my former schoolmates and classmates. For documentary purposes, I had the entire operation filmed through the courtesy of the Shanghai Branch of the Chinese Medical Association. More than 100 open heart operations have been performed under acupuncture anesthesia in that hospital since its first on April 19,1972, with a success rate of over 90 percent. The types of congenital heart disease so treated included ventricular septal defect, atria1 septal defect, pulmonary stenosis, trilogy of Fallot, tetralogy of Fallot and ruptured aortic sinus of Valsalva with ventricular septal defect. The youngest patient was 10 years of age and the longest period of extracorporeal circulation was 121 minutes. My Chinese colleagues neither considered acupuncture anesthesia to be a panacea for all open heart operations nor claimed perfection with this technique. Three “castles” or hurdles still remain in acupuncture anesthesia: incomplete relief of painful sensations during closure of median sternotomy, incomplete muscular relaxation during abdominal operations and uncomfortable sensation during mesenteric traction of gut handling. However, my Chinese colleagues are determined to lick these problems. Physicians in the western world tend to be somewhat critical of happenings that cannot be explained on a “scientific” basis. In fact, some even called acupuncture anesthesia a form of hypnosis. Such an attitude reflects ignorance and mulishness. I suggest to some of my American colleagues that we keep our mouths closed but our eyes open for further progress and development emanating from the medical horizons in the People’s Republic of China. Tsung 0. Cheng. MD, FACC Division of Cardiology Department of Medicine The George Washington University Medical Center Washington, D. C. Reference 1. Katz AM:
Acupuncture anesthesia for open heart surSery. A C~SB report. Am J Cardial 34:250-253. 1974
ACUPUNCTURE
ANESTHESIA-II
Medical journals should publish reports of clinical studies of methods that seem unlikely to be successful by our previous experience; there would be no progress otherwise. But this report of Dr. Katz is, in the language of the courtroom, hearsay evidence. Katz was not the physician in charge; he was not the surgeon; his closest contact to the patient was observation in the operating room. There is no evidence that he examined the patient beyond his observations in the operating theater. I doubt that you would publish a case report submitted by an observer, however interested, whose evidence consisted of the material presented here.
September 1975
Reuben Berman, MD Editor Minnesota
The American Journal of CARDIOLOGY
Medicine
Volume 36
411
