1494 Lettm BO the Editor December 1993

American Heart Journal

REPLY

To the Editor: In reference to the comments of Drs. Cullen and Redington, we

stress that we could not find a single patient with postductal co- arctation of the aorta to include in our study, as we specifically mentioned in the Methods section of our article. Therefore we agree with Cullen and Redington that our results cannot be gen- eralized to patients within this rare subgroup. We have not come across a neonate with postductal coarctation in the last 4 years.

Claudia Ramaciotti, MD The Children’s Hospital of Philadelphia

34th St. and Civic Center Blvd. Philadelphia, PA 19104

4/8/49973

UMBILICAL VEIN CARDIAC CATHETERIZATION

To the Editor: We read with great interest the recent report on umblical vein

catheterization in which a venous sheath is used.l We appreciate the problem of intermittent spasm of the ductus venosum inter- fering with change of catheters during cardiac catheterization, and we have also started using a venous sheath in the umblical vein; our experience with this- technique is limited to three patients. The first patient was a boy with complete transposition of the great ar- teries; he underwent balloon atria1 septostomy when he was 36 hours old. The catheter was introduced through a 6F venous sheath placed in the umblical vein. The second baby underwent diagnostic catheterization for pulmonary atresia, ventricular sep- tal defect, and patent ductus arteriosus at the age of 6 days before corrective surgery. A 5F angiographic balloon catheter was used through a 5F venoussheath placed in the umblical vein. The right atrium, right ventricle, and left atrium were entered during the study, and no difficulties were encountered. The third baby was seen when he was 8 hours old; he had complete heart block and a fixed ventricular rate of 40 beats/min. At age 36 hours the ventric- ular rate dropped further to 25 to 30 beats/mm and he had recur- rent episodes of nonsustained ventricular tachycardia. A 5F tem- porary pacing lead was placed through a ‘5F venous sheath intro- duced in the umblical vein.

We have been using a 20G venous cannula to enter the umblical vein after its local exposure. A guide wire (0.025 inch) is passed through this cannula to enter the right atrium. The venous sheath is introduced over the wire and, with little manipulation, it can be made to enter the right atrium. There were no complications in any of our patients, We agree with the author& viewpoint as to the advantages of this procedure. This approach is easy and secures a venous line quickly. It is recommended for cardiac catheterization during early neonatal life, especially in an emergency situation, as was exemplified by the third patient in our series.

Anita Saxena, MD Pankaj Vohra, MD

Yogesh Jain, MD Suresh Narayanan, MD R. Krishna Kumar, MD

Departments of Cardiology and Pediatrics All India Institute of Medical Sciences

New Delhi, India 110029

REFERENCE

1. Appleton RS, Jureidini SB, Balfour JC, Nouri S. Venous sheath to facilitate cardiac catheterization via the umblical vein. AM HEART J 1992;124:1392-3.

4/8/49962

REPLY

To the Editor: The comments of Saxsena et al. are much appreciated. We agree

that this technique is relatively easy and is important for securing the venous line quickly. We were particularly intrigued by the use of the temporary transvenous pacing through the umbilical vein venous sheath introduced through the umbilical vein. Yours is an- other example of the merits of this technique. Another advantage of using a venous sheath over direct placement is that a sterile sleeve can be placed over the sheath and catheter to permit ma- nipulation of the pacemaker catheter at a later time if the trans- venous pacemaker catheter became dislodged. We, too, had such an experience with one newborn with complete heart block and transposition of the great arteries.

We like the authors’ technique of entering the umbilical vein. We have primarily used a traditional neonatology approach for establishing the first line, but we can see that the use of a 20 gauge catheter with a wire is another technique that is valuable in gain- ing venous access. Thank you for your kind statements.

Robert Scott Appleton, MD Saadeh B. Jureidini, MD

Ian Balfour, MD Soraya Now-i, MD

Division of Pediatric Cardiology Department of Pediatrics

Cardinal Glennon Hospital/St. Louis University St. Louis, MO 63104

4/S/49969

DILTIAZEM MYOPATHY

To the Editor: A 58-year-old man with hypertension, coronary artery disease,

and hypercholesterolemia had been treated with nitrates, dilt- iazem, enalapril, and lovastatin for 2 years. Recently the patient had an acute onset of pain in the lower part of both legs so severe as to impede his ability to walk. He also complained of pain in both upper extremities and chest pain accompanied by generalized weakness. The only remarkable physical finding was muscle ten- derness to palpation. An electrocardiogram was unchanged. A clinical diagnosis of myopathy was made. Laboratory tests re- vealed that liver and thyroid functions were normal, but creatine- phosphokinase (CPK) levels were 4000 U/L. Fractionation of CPK revealed 100% of CPK-MM and normal MB and BB fractions. Because lovastatin is well known to be myotoxic, it was withdrawn, but repeat CPK levels were still 4000+ U/L. Results of a workup for a connective tissue disorder were negative. There was no evi- dence of rhabdomyolysis, and renal function was normal. Electro- myogram revealed a myopathic pattern. The patient refused to undergo muscle biopsy. His myopathic symptoms were getting worse; therefore diltiazem was discontinued immediately. One week after the withdrawal of diltiazem. his myopathy improved