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EDITORIALS
are normal inhabitants.
Yet, in this issue (see page 358) and the July issue5 three potentially lethal reactions were reported
because of penicillin. These life-threatening reactions could not have been predicted with the use of
any available pharmacologic data. However, each
patient had a distinct susceptibility for a serious reaction. The reasons for the heightened susceptibility were different. In two patients there was an
unusual state of immunologic reactivity. Could this
have been predicted? Another patient was debilitated and had organic heart disease and was therefore susceptible to the potassium administered with
the penicillin. Could this have been predicted?
The answer to these questions is probably no. The
magnitude of such problems, however, mandates
that the question be asked repeatedly.
In order to decrease the incidence of adverse drug
reactions physicians must not only have intimate
knowledge of drugs, but they must also have intimate knowledge of the patients in whom they are to
be used.
Bernurd H. Booth, M . D .
Jackson,Mississippi
1 Haddinet BC, Gowdy CW, Coulter WK, et al: Drug
reactions and errors in administration on a medical ward.
Canad Med Ass J 97: 1450-1457, 1967
2 Honvitz N: Admissions to hospital due to drugs. Br Med J
1 :539-540, 1969
3 Seidl LC, Thornton CF, Smith JW, et al: Studies on the
epidemiology of adverse drug reactions. 111. Reactions in
patients on a general medical senice. Bull Hopkins Hosp
111 :299-315, 1966
4 United States Department of Health, Education and Welfare, Task Force on Prescription Drugs: Final report.
Washington, D.C. Government Printing Office, 1969
5 Petsas A, Kotler MN: Electrocardiographic changes associated with penicillin anaphylaxis. Chest 64:66-69, 1W3
Obstruction to Pulmonary Venous
Return Obscured by Decreased
Pulmonary Blood Flow
I n this issue of Chest, Muster et a1 describe two
small infants with the rare combination of tetralogy of Fallot and total anomalous pulmonary venous
drainage. Both patients died when surgery for increased pulmonary blood flow as palliation for the
tetralogy resulted in worsening of the previously
unsuspected pulmonary obstruction associated with
the anomalous veins. Obstruction to pulmonary
venous return ( e g , total anomalous pulmonary
venous drainage, mitral stenosis and atresia, cor triatriatum) may be especially difficult to diagnose in
the presence of another defect which includes pulmonic stenosis. When pulmonary blood flow is de-
creased, the clinical signs of pulmonary venous obstruction may be absent, and pulmonary venous
pressure may not be unduly elevated. After a systemic pulmonary-arterial shunt is established surgically, the obstruction is exaggerated and pulmonary
venous pressure rises precipitously, resulting in pulmonary edema with all of its manifestations.
Unfortunately, congestive heart failure is relatively common following aortic-pulmonary arterial
shunts established during infancy, even in uncomplicated situations. Thus, when pulmonary congestion occurs after operation, additional undetected
pulmonary venous obstruction will often not be immediately suspected. The possibility of an additional
left-sided obstructive lesion, however, adds justification to the principle that patients with congestive
heart failure after operation should have repeat cardiac catheterization promptly, especially if response
to medical therapy is marginal. If, as in most instances, the shunt is simply too large, surgical
modification of the anastomosis can be carried out as
necessary. On the other hand, when an associated
pulmonary venous obstructive lesion is found to be
present, palliation or surgical repair of the additional defect is in order. Recently, at this institution, a patient with ventricular septa1 defect and
pulmonary atresia developed pulmonary edema following a Waterston shunt. A second cardiac
catheterization revealed that the mean .left atrial
pressure had risen from 4 to 35 mm Hg, secondary
to increased pulmonary blood flow, previously unrecognized mitral atresia, and a small patent
foramen ovale. Balloon septostomy produced an excellent palliative result.
Cardiac catheterization and angiography in infancy are carried out at low risk in experienced
laboratories. A seriously ill baby with previously
unrecognized congenital heart disease must always
be studied without unnecessary delay. Similarly, as
mentioned by Muster, specific hemodynamic data
also must be promptly obtained in the infant whose
clhical course has been poor after opration. In the
modem era of the aggressive approach to the diagnosis of congenital heart disease in infancy, unusual
combinations of defects may be recognized during
life rather than in the pathology laboratory. Only
when complete hemodynamic information is available, can rational management be instituted and a
successful outcome achieved.
Welton M . Gersony, M . D . *
New York, N.Y.
---
*Director, Division of Pediatric Cardiology, Colle e of Physicians and Surgeons, Columbia-Presbyterian ~ e s i c a lCenter.
Reprint requests: Dr. Cersony, Babies Hospital Annex, Room
102,3975 Broadmy, New York City 10032
CHEST, VOL. 64, NO. 3, SEPTEMBER, 1973
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