Letters Long- Term Psychologic Implications of Congenital Heart Disease I read with interest the article entitled "Long-Term Psychologic Implications of Congenital Heart Disease: A 25-Year Follow-Up" by Brandhagen and colleagues, which was published in the May 1991 issue of the Mayo Clinic Proceedings (pages 474 to 479). The authors concluded that adults with congenital heart disease have higher levels of stress as well as greater educational and occupational achievements than do adults without congenital heart disease. Unfortunately, the authors' use of normative data rather than appropriate control subjects allows for alternative interpretations of their observations. Educational and vocational achievements are probably characteristics of families who seek medical care at internationally renowned medical centers. Patients who receive medical care at local or regional hospitals may be both less educated and less affluent. Healthy siblings of patients would have been ideal control subjects for the study. In addition, performing a similar study at a medical center that provides care for virtually all the patients in a geographic region would have been interesting. William Pearl, M.D. Chief, Pediatric Cardiology William Beaumont Army Medical Center ElPaso, Texas
Drs. Feldt and Williams reply We appreciate Dr. Pearl's comments on our report on the longterm psychologic implications of congenital heart disease. We are well aware of the deficiencies of our study design. The type of psychologic testing chosen for our mail-in format included normative data, which seemed the best available approach. Although healthy siblings may have been ideal control subjects, contacting them seemed impractical and most likely would have decreased the high response rate from the patient questionnaires. No demographic data are available for our patient population at the time of our study; however, we know that, generally, more than 50% _of Mayo patients with congenital heart disease reside in the Upper Midwest. Certainly, no data are available on the occupational or educational achievements of these patients' parents or siblings; thus, we have no method for comparing their educational and vocational achievements with the normal range. Mayo Clin Proc 67:201-202, 1992
Our study raises important questions for which we do not, as yet, have answers. Why is the degree of stress higher in adults with congenital heart disease than in "normal" adults, and why is it high regardless of the severity of the cardiac defect? Clearly, this subject should be pursued in more detail. That the results in our patient population correlated well with theexisting literature on stress, type A behavior, and achievement as risk factors for adult patients with cardiac disease is interesting. Internists and cardiologists who usually examine these patients when they become adults must address the previously mentioned issues. We believe that our article appropriately suggests stress as a sequela of the cardiac defect, but this phenomenon is not well understood as yet. Future studies in this area are clearly needed. Robert H. Feldt, M.D. Donald E. Williams, Ph.D.
Pericardial Disease The case report by Moder and colleagues, which was published in the November 1991 issue of the Mayo Clinic Proceedings (pages 1127 to 1130), contains many valuable lessons for anyone concerned with pericardial disease. During a lifetime as a "pericardiologist,' I have not encountered a comparable case in which the initial manifestation was pulseless extremities. After reading the report, I have several questions that I am certain the authors can answer. For example, what was the patient's chief complaint? Did he complain of "cold cyanotic extremities"? In the case report, the authors describe minimal shortness of breath and generalized fatigue; were they the chief complaints? If so, the initial problem is not rare, although the complete absence of pulses in many peripheral arteries is, of course, rare. The latter situation, however, raises a question about.the pulsus paradoxus of 15 mm Hg, which was recorded before the patient was transferred to the medical intensive-care unit. In which artery was that measurement determined? Did the patient have an arterial catheter placed before he was taken to the intensive-care unit? If Korotkoff sounds were detected in the customary location-the brachial artery-this finding should be mentioned because of the absence of a palpable pulse (although such sounds could be reasonable concurrences). The positive result of the cytologic test of the pericardial fluid is notable because of the relatively good performance of 201
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therapeutic taps (as in this case) for diagnosis versus "diagnostic" taps, which provide minimal diagnostic information. The authors quote me (theirreference 1) as stating"...as little as 250 ml during rapid accumulation" will cause tamponade. Actually, in that study, I noted that as little as 150 ml is capable of compressing the heart in acute injuries to the heart and brisk bleeding. In contrast, a 200- to 250-ml increase in pericardial contents may be the threshold for roentgenographic recognition of fluid-provoked enlargement of the cardiac silhouette. In the case report, bacterial infections are listed among the most common causes of tamponade, but actually in the United States, viral infections are much more common. Indeed, the commonality of etiologic factors depends on the patient population, a point that is worth emphasizing. For example, in pericardial disease, as in many other diseases, Mayo Clinic physicians encounter patients who have been referred not only because of a difficult condition but also because of an unusual cause or pathogenesis of a condition. Finally, the statement that" ...the overall survival rate of patients was not significantly improved by more extensive resections" probably applies strictly to patients with malignant tumors and other life-threatening conditions. My comments are meant only to supplement and emend an otherwise excellent report of an unusual case associated with many "pearls" for clinicians (for example, the importance of intermittent rather than steady drainage of the pericardium with use of a catheter). DavidH. Spodick, M.D., D.Sc. Cardiology Division Saint Vincent Hospital Worcester, Massachusetts
The authors reply We appreciate Dr. Spodick's comments and questions. In regard to the first question, the patient's chief complaints on admission were generalized fatigue and minimal shortness of breath; however, the most outstanding physical finding was the absence of palpable pulses-the unusual aspect of the patient's condition. Pulsus paradoxus was detected by auscultation of the patient's right brachial artery. Nonetheless, a pulse was not palpable over that site. Furthermore, the patient did not have an arterial line at the time of this measurement. Dr. Spodick's other comments including the utility of a therapeutic tap in diagnosis, the volumes of fluid necessary to cause tamponade, and the fact that viral rather than bacterial infections are more common causes of tamponade in the United States are salient points. Additionally, his suggestion that the limited benefits of more extensive resections refer "to patients with malignant tumors and other life-threatening conditions" is well taken. Kevin G. Moder, M.D. David N. Mohr, M.D. JamesB. Seward, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion ofthe Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.
Drs. Feldt and Williams reply We appreciate Dr. Pearl's comments on our report on the longterm psychologic implications of congenital heart disease. We are well aware of the deficiencies of our study design. The type of psychologic testing chosen for our mail-in format included normative data, which seemed the best available approach. Although healthy siblings may have been ideal control subjects, contacting them seemed impractical and most likely would have decreased the high response rate from the patient questionnaires. No demographic data are available for our patient population at the time of our study; however, we know that, generally, more than 50% _of Mayo patients with congenital heart disease reside in the Upper Midwest. Certainly, no data are available on the occupational or educational achievements of these patients' parents or siblings; thus, we have no method for comparing their educational and vocational achievements with the normal range. Mayo Clin Proc 67:201-202, 1992
Our study raises important questions for which we do not, as yet, have answers. Why is the degree of stress higher in adults with congenital heart disease than in "normal" adults, and why is it high regardless of the severity of the cardiac defect? Clearly, this subject should be pursued in more detail. That the results in our patient population correlated well with theexisting literature on stress, type A behavior, and achievement as risk factors for adult patients with cardiac disease is interesting. Internists and cardiologists who usually examine these patients when they become adults must address the previously mentioned issues. We believe that our article appropriately suggests stress as a sequela of the cardiac defect, but this phenomenon is not well understood as yet. Future studies in this area are clearly needed. Robert H. Feldt, M.D. Donald E. Williams, Ph.D.
Pericardial Disease The case report by Moder and colleagues, which was published in the November 1991 issue of the Mayo Clinic Proceedings (pages 1127 to 1130), contains many valuable lessons for anyone concerned with pericardial disease. During a lifetime as a "pericardiologist,' I have not encountered a comparable case in which the initial manifestation was pulseless extremities. After reading the report, I have several questions that I am certain the authors can answer. For example, what was the patient's chief complaint? Did he complain of "cold cyanotic extremities"? In the case report, the authors describe minimal shortness of breath and generalized fatigue; were they the chief complaints? If so, the initial problem is not rare, although the complete absence of pulses in many peripheral arteries is, of course, rare. The latter situation, however, raises a question about.the pulsus paradoxus of 15 mm Hg, which was recorded before the patient was transferred to the medical intensive-care unit. In which artery was that measurement determined? Did the patient have an arterial catheter placed before he was taken to the intensive-care unit? If Korotkoff sounds were detected in the customary location-the brachial artery-this finding should be mentioned because of the absence of a palpable pulse (although such sounds could be reasonable concurrences). The positive result of the cytologic test of the pericardial fluid is notable because of the relatively good performance of 201
202
LETTERS
Mayo Clln Proc, February 1992, Vol 67
therapeutic taps (as in this case) for diagnosis versus "diagnostic" taps, which provide minimal diagnostic information. The authors quote me (theirreference 1) as stating"...as little as 250 ml during rapid accumulation" will cause tamponade. Actually, in that study, I noted that as little as 150 ml is capable of compressing the heart in acute injuries to the heart and brisk bleeding. In contrast, a 200- to 250-ml increase in pericardial contents may be the threshold for roentgenographic recognition of fluid-provoked enlargement of the cardiac silhouette. In the case report, bacterial infections are listed among the most common causes of tamponade, but actually in the United States, viral infections are much more common. Indeed, the commonality of etiologic factors depends on the patient population, a point that is worth emphasizing. For example, in pericardial disease, as in many other diseases, Mayo Clinic physicians encounter patients who have been referred not only because of a difficult condition but also because of an unusual cause or pathogenesis of a condition. Finally, the statement that" ...the overall survival rate of patients was not significantly improved by more extensive resections" probably applies strictly to patients with malignant tumors and other life-threatening conditions. My comments are meant only to supplement and emend an otherwise excellent report of an unusual case associated with many "pearls" for clinicians (for example, the importance of intermittent rather than steady drainage of the pericardium with use of a catheter). DavidH. Spodick, M.D., D.Sc. Cardiology Division Saint Vincent Hospital Worcester, Massachusetts
The authors reply We appreciate Dr. Spodick's comments and questions. In regard to the first question, the patient's chief complaints on admission were generalized fatigue and minimal shortness of breath; however, the most outstanding physical finding was the absence of palpable pulses-the unusual aspect of the patient's condition. Pulsus paradoxus was detected by auscultation of the patient's right brachial artery. Nonetheless, a pulse was not palpable over that site. Furthermore, the patient did not have an arterial line at the time of this measurement. Dr. Spodick's other comments including the utility of a therapeutic tap in diagnosis, the volumes of fluid necessary to cause tamponade, and the fact that viral rather than bacterial infections are more common causes of tamponade in the United States are salient points. Additionally, his suggestion that the limited benefits of more extensive resections refer "to patients with malignant tumors and other life-threatening conditions" is well taken. Kevin G. Moder, M.D. David N. Mohr, M.D. JamesB. Seward, M.D.
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words and contain no more than 5 references. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion ofthe Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.
