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Correction
to
Carabello and Crawford,
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Careful follow-up shows that patients with valvular heart disease are often in a border zone, with symptoms that cannot be confidently attributed to their valvular lesions. We have found that stress echocardiography is extremely helpful as a means of assessing these patients objectively and further clarifying the pathophysiology of their symptoms and echocardiographic findings at rest. The assessment of exercise-induced pulmonary hypertension, exercise-induced transvalvular gradients, myocardial reserve, left ventricular end-systolic index during exercise, right ventricular function after exercise, exercise capacity, and sometimes, exercise-induced systemic hypertension often has a major impact on patient care.2,3,4 Echocardiographers should be encouraged to explore exercise physiology using the various methods available with this imaging technique to evaluate patients with valvular heart disease further — beyond the indecisive findings obtained from patients at rest — and to an even greater extent than has previously been done invasively in the catheterization laboratory.
Micha S. Feinberg, M.D.
Ehud Schwammenthal, M.D.
Zvi Vered, M.D.
Sheba Medical Center
Tel Hashomer 52621, Israel
References
Also, in the third line of the second column of page 37, should the term be mitral regurgitation rather than mitral stenosis?
Howard Homler, M.D.
6401 Coyle Ave.
Carmichael, CA 95608
To the Editor: Feinberg et al. point out that many patients have coronary disease as the underlying cause of their mitral regurgitation. We entirely agree but did not address this point in our review because mitral regurgitation due to coronary disease represents two heart diseases instead of one valvular disease. In a given case, the outcome may be determined more by the progression of coronary disease than by the valve lesion, thus making general statements about the management of ischemic mitral regurgitation very difficult. Ischemic mitral regurgitation continues to be an extremely difficult disease to manage, with a poor outcome relative to that of nonischemic mitral regurgitation. Further complicating the issue, mitral-valve repair may be problematic in ischemic mitral regurgitation, since the valve itself may be relatively normal. Thus, some have advocated mitral-valve replacement as superior to mitral-valve repair in this entity.1
We agree that exercise echocardiography may be helpful in a patient with mitral regurgitation in establishing both symptom status and the origin of exercise-related symptoms. Indeed, there are data in the literature to support this approach.2,3 However, in our opinion, longer follow-up of a larger number of patients will be necessary to establish the exact role of echocardiography in the timing of valve surgery for mitral regurgitation.
We concur with Dr. Homler that prophylaxis against repeated streptococcal infection is indicated in young patients with a history of rheumatic fever. However, the age at which this prophylaxis may safely be discontinued remains debatable and is unlikely to be resolved in the near future owing to apparent differences in the nature of rheumatic fever in different parts of the world. We thank Dr. Homler for noting the error on page 37. Indeed, we were referring to mitral regurgitation rather than mitral stenosis.
Blase A. Carabello, M.D.
Fred Crawford, M.D.
Medical University of South Carolina
Charleston, SC 29425-2221
References
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