our preference for the terms doubly committed and juxta- (or sub) arteria1.2,3Once this single anatomic fact is recognized, all the apparent D. hby-kh, MD confusion discussedby Ludomirsky Leeds, United Kingdom et al’ with regard to distinction 12 March 1991 from obstruction in the outflow tract of the right ventricle is dis1. Caterina R, D’Ascanio A, Mazzone A, pelled. Gazzetti P, Bernini W, Neri R, BombarRobartn. -, m. 0K chieri S. Prevalence of anticardiolipin London, United Kingdom antibodies in coronary artery disease. Am 12 March 1991
defining seropositivity in the laboratory and allow accurate studies on associateddiseasepatterns to be performed.5
J Cardiol 1990;65:922-923. 2. Klemp P, Cooper RC, Strauss FJ, Jordaan ER, Przybojewki JZ, Nel N. Anticardiolipin antibodies in ischaemic heart disease. Clin Exp Immunol1988;14:254251. 3. Hamsten A, Bjorkholm M, Nonberg R, de Faine U, Holm G. Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events. Lancer 1986; 2:1353-1356. 4. Keane A, Woods R, Dowding V, Roden D, Barry C. Anticardiolipin antibodies in rheumatoid arthritis. Brit J Rheumatol 1987;26:346-350. 5. Hughes GRV. Vascular disease, thrombosis and recurrent abortion. Br &fed J 1988;247:700-701.
Diagnosing and Differentiating a Doubly Committed Ventricular Septal Defect from Obstruction in the Oufflow Tract of the Right Ventricle It was with some surprise that I noted that comments on the fact that “approximately 5% of ventricular septal defects are located high in the right ventricular outflow tract between the crista supraventricularis and the pulmonic valve”’ referenced one of my published studies2 In that study, my colleagues and I pointed to the confusion that could occur when “supracristal” was used as a descriptor for such defects. In reality, the key to diagnosis of these defects is the observation that the entirety of the muscular outlet septum, together with the “septal” aspectof the muscular subpulmonary infundibulum, is totally lacking. Because of this, the leaflets of the pulmonary valves are in fibrous continuity with those of the aortic valve, and the interventricular communication sits beneath both outflow tracts: hence,
1. Ludomirsky A, Tani L, Murphy DJ, Huhta JC. Usefulness of color-flow Dopp ler in diagnosing and in differentiating supracristal ventricular septal defect from right ventricular outflow tract obstruction. Am J Cardiol 1991;67:194-198. 2. Anderson RH, Lenox CC, Zuberbuhler JR. The morphology of ventricular septal defects. Perspect Pediatr Pathol 1984;8:235-268. 3. Baker E, Leung MP, Anderson RH, Fischer DR, Zuberbuhler JR. The crosssectional anatomy of ventricular septal defects: a reappraisal. Br Heart J 1988; 59:339-351.
Natural History of Cardiac Rhabdomyoma I read with interest the article by Smythe et al’ and agree with their comments concerning the invariable spontaneousregression of cardiac rhabdomyoma. In 1987 my colleaguesand I described a caseof cardiac rhabdomyoma diagnosed and followed up prenatally and for 2 years after delivery by Doppler echocardiography. Spontaneous regression of multiple tumor masseswas documented, thus adding another case to the 15 patients cited by Smythe et al with evidence of tumor regression. More important, I wish to highlight the significant contribution of repeated Doppler examinations in the hemodynamic evaluation and management of such patients, which can help to avoid repeated cardiac catheterizations and unnecessary surgery. Doppler detection of mitral and pulmonary regurgitation was consequent to tumor massesinterfering with valve closure. Pulmonary regurgitation disappeared concomitantly with tumor massregression. Thus I consider the Dopp ler modality, not alluded to in your
article, to be more important and cost-effective than “magnetic resonance imaging” to “assist in charting the course of the lesion.” Edward0. Ablnubr, MD Haifa, Israel 28 March 1991 1. Smythe JF, Dyck JD, Smallhorn JF, Freedom RM. Natural history of cardiac rhabdomyoma in infancy and childhood. Am J Cardiol 1990;66: 1247-l 249. 2. Abinader EG, Goldhammer I, Sharf M, Reiter A, Berger A. The usefulness of Doppler echocardiography in the management of rhahdomyoma diagnosed prenatally. Eur Heart J 1987;8:1146-1152.
Metoprolol as Antihypertensive
Drug
We read with interest the article of Schrader et al’ on the comparison of the antihypertensive efficiency of nitrendipine, metoprolol, mepindolol and enalapril using ambulatory 24-hour blood pressure monitoring. Although the investigators demonstrated in an elegant way the effectivenessof the antihypertensive drugs, they overlooked the potential hazards of using /3blocking drugs, such as metoprolol, for the treatment of arterial hypertension. It is now widely accepted that this drug doeshave deleterious effects on the lipid metabolism, which could eventually be more harmful to the patient.2,3 Significant increase in triglycerides, total cholesterol and the atherogenic index as estimated by the ratio LDL/HDL cholesterol concentrations together with a decrease in HDL cholesterol are some of the most altered metabolic parameters that deserverecognition, becausein some casesthese might counteract the possiblebenefit of a reduction in blood pressure or the prevention of coronary artery disease. In contrast to the observations of White et aL4 nitrendipine reduced the average daily blood pressure, one of the important predictors of hypertensive heart diseases. Becauseantihypertensive therapy implies continued and prolonged drug administration, agents with neutral or favorable effects on lipid metabolism such as nitrendipine,5 READERS’COMMENTS 831
defining seropositivity in the laboratory and allow accurate studies on associateddiseasepatterns to be performed.5
J Cardiol 1990;65:922-923. 2. Klemp P, Cooper RC, Strauss FJ, Jordaan ER, Przybojewki JZ, Nel N. Anticardiolipin antibodies in ischaemic heart disease. Clin Exp Immunol1988;14:254251. 3. Hamsten A, Bjorkholm M, Nonberg R, de Faine U, Holm G. Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events. Lancer 1986; 2:1353-1356. 4. Keane A, Woods R, Dowding V, Roden D, Barry C. Anticardiolipin antibodies in rheumatoid arthritis. Brit J Rheumatol 1987;26:346-350. 5. Hughes GRV. Vascular disease, thrombosis and recurrent abortion. Br &fed J 1988;247:700-701.
Diagnosing and Differentiating a Doubly Committed Ventricular Septal Defect from Obstruction in the Oufflow Tract of the Right Ventricle It was with some surprise that I noted that comments on the fact that “approximately 5% of ventricular septal defects are located high in the right ventricular outflow tract between the crista supraventricularis and the pulmonic valve”’ referenced one of my published studies2 In that study, my colleagues and I pointed to the confusion that could occur when “supracristal” was used as a descriptor for such defects. In reality, the key to diagnosis of these defects is the observation that the entirety of the muscular outlet septum, together with the “septal” aspectof the muscular subpulmonary infundibulum, is totally lacking. Because of this, the leaflets of the pulmonary valves are in fibrous continuity with those of the aortic valve, and the interventricular communication sits beneath both outflow tracts: hence,
1. Ludomirsky A, Tani L, Murphy DJ, Huhta JC. Usefulness of color-flow Dopp ler in diagnosing and in differentiating supracristal ventricular septal defect from right ventricular outflow tract obstruction. Am J Cardiol 1991;67:194-198. 2. Anderson RH, Lenox CC, Zuberbuhler JR. The morphology of ventricular septal defects. Perspect Pediatr Pathol 1984;8:235-268. 3. Baker E, Leung MP, Anderson RH, Fischer DR, Zuberbuhler JR. The crosssectional anatomy of ventricular septal defects: a reappraisal. Br Heart J 1988; 59:339-351.
Natural History of Cardiac Rhabdomyoma I read with interest the article by Smythe et al’ and agree with their comments concerning the invariable spontaneousregression of cardiac rhabdomyoma. In 1987 my colleaguesand I described a caseof cardiac rhabdomyoma diagnosed and followed up prenatally and for 2 years after delivery by Doppler echocardiography. Spontaneous regression of multiple tumor masseswas documented, thus adding another case to the 15 patients cited by Smythe et al with evidence of tumor regression. More important, I wish to highlight the significant contribution of repeated Doppler examinations in the hemodynamic evaluation and management of such patients, which can help to avoid repeated cardiac catheterizations and unnecessary surgery. Doppler detection of mitral and pulmonary regurgitation was consequent to tumor massesinterfering with valve closure. Pulmonary regurgitation disappeared concomitantly with tumor massregression. Thus I consider the Dopp ler modality, not alluded to in your
article, to be more important and cost-effective than “magnetic resonance imaging” to “assist in charting the course of the lesion.” Edward0. Ablnubr, MD Haifa, Israel 28 March 1991 1. Smythe JF, Dyck JD, Smallhorn JF, Freedom RM. Natural history of cardiac rhabdomyoma in infancy and childhood. Am J Cardiol 1990;66: 1247-l 249. 2. Abinader EG, Goldhammer I, Sharf M, Reiter A, Berger A. The usefulness of Doppler echocardiography in the management of rhahdomyoma diagnosed prenatally. Eur Heart J 1987;8:1146-1152.
Metoprolol as Antihypertensive
Drug
We read with interest the article of Schrader et al’ on the comparison of the antihypertensive efficiency of nitrendipine, metoprolol, mepindolol and enalapril using ambulatory 24-hour blood pressure monitoring. Although the investigators demonstrated in an elegant way the effectivenessof the antihypertensive drugs, they overlooked the potential hazards of using /3blocking drugs, such as metoprolol, for the treatment of arterial hypertension. It is now widely accepted that this drug doeshave deleterious effects on the lipid metabolism, which could eventually be more harmful to the patient.2,3 Significant increase in triglycerides, total cholesterol and the atherogenic index as estimated by the ratio LDL/HDL cholesterol concentrations together with a decrease in HDL cholesterol are some of the most altered metabolic parameters that deserverecognition, becausein some casesthese might counteract the possiblebenefit of a reduction in blood pressure or the prevention of coronary artery disease. In contrast to the observations of White et aL4 nitrendipine reduced the average daily blood pressure, one of the important predictors of hypertensive heart diseases. Becauseantihypertensive therapy implies continued and prolonged drug administration, agents with neutral or favorable effects on lipid metabolism such as nitrendipine,5 READERS’COMMENTS 831
