To the Editor:-According to Anesthesiology's Guide for Authors,* "review articles are comprehensive surveys that synthesize older ideas and suggest new ones" It is with this in mind that the otherwise excellent review by Hanson et al. [1]concerning mitral valve prolapse falls short. Specifically, they had the forum and, therefore, the opportunity, to suggest an approach for clinicians confronted with an otherwise asymptomatic patient who on physical examination is for the first time, noted to have a systolic murmur and is scheduled for gastrointestinal, genitourinary, dental, or respiratory tract surgery. These patients may or may not have mitral valve prolapse. The dilemma is whether to prescribe prophylactic antibiotics. Most anesthesiologists do not have the expertise to make the definitive diagnosis, and consultation from a cardiologist on the day of surgery is frequently unobtainable. To cancel these elective surgeries in this era of managed care can cause enormous expense and patient inconvenience. One approach would be to prescribe prophylactic antibiotics empirically to all patients who happen to have a murmur. The trouble with this approach, as the authors correctly imply, is that the risk of anaphylaxis to the antibiotics is probably greater than the risk of endocarditis. [2]In addition, antibiotic prophylaxis has never been proven effective. [2]Because the authors chose not to suggest an approach and because, to the best of my knowledge, no literature is available that addresses this problem, I suggest the following. If the patient at risk is presenting for dental or respiratory tract surgery, erythromycin should empirically be given orally 2 h before surgery; then a dose 6 h later. This approach is based on the assumption that the incidence of anaphylaxis to erythromycin is less than the incidence of anaphylaxis to amoxicillin. The situation is more complex for patients presenting for gastrointestinal or genitourinary surgery. Here, the offending organism is enterococcus. [3]The only viable alternative to intravenous ampicillin (amoxicillin) and gentamicin therapy is vancomycin and gentamicin. [3]In my judgment, vancomycin is not a drug "to be taken lightly." Therefore, I would suggest that, in this case, the anesthesiologist explain the situation to the surgeon and patient and present two reasonable options. First, cancel surgery, pending a cardiovascular consultation. Second, proceed without antibiotic coverage, with the understanding that the evidence for efficacy of prophylaxis is lacking. [2]In either case, I would document the discussions and decisions clearly in the medical record, and schedule the patient for medical followup at a later time.

Bruce Kleinman, M.D., Chief, Anesthesiology, Edward Hines Jr. VA Hospital, Stritch School of Medicine, Department of Anesthesiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, Illinois 60153.

(Accepted for publication August 28, 1996.)

*Guide for Authors. Anesthesiology 1996; 85:37A-38A.

Hanson EW, Neerhut RK, Lynch C: Mitral valve prolapse. Anesthesiology 1996; 85:178-95.
Durack DT: Prevention of infective endocarditis. N Engl J Med 1995; 332:38-44.
Dajani AS, Bisno AL, Chung KJ, Durack DT, Freed M, Gerber MA, Karchmer AW, Millard HD, Rahimtoola S, Shulman ST, Watanakunakorn C, Taubert KA: Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1990; 264:2919-22.