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Ann Thorac Surg 2002;73:1357-1358
© 2002 The Society of Thoracic Surgeons

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Correspondence

Open lung biopsy in patients with congenital heart disease

^a Department of Pediatric Cardiology, University Medical Center, INF 153, D-69120 Heidelberg, Germany

e-mail: matthiasgorenflo{at}med.uni-heidelberg.de

To the Editor

With great interest, I have read the article by Jaklitsch and coworkers [1]. The authors addressed the importance of lung biopsy in deciding therapeutic strategies for children, especially with pulmonary hypertension. However, several of their findings need explanation. A grading of pulmonary vascular pathology was performed in 17 of 18 patients with pulmonary hypertension and was related to the mean pulmonary artery pressure (Fig 1A in the original article) and also to the ratio of pulmonary to systemic vascular resistance (Rp/Rs, Fig 1B in the original article). It is surprising that the single patient with grade IV vascular pathology according to Heath and colleagues [2] had only a mean PA pressure of about 25 mm Hg and a Rp/Rs ratio of about 0.3 (Fig 1A and B in the original article); in other words, pulmonary hypertension defined by common criteria [3] obviously was not a problem in this particular patient. Despite these hemodynamic findings, the authors state that—as a consequence of lung biopsy findings—intracardiac repair was not performed in this patient. Moreover, 2 patients with a ratio Rp/Rs greater than 1, that is, with systemic or even suprasystemic resistance to pulmonary perfusion, were found to have medial hypertrophy only, according to the Heath-Edwards grade I they were assigned. Although we agree from our own experience [4] that the correlation between hemodynamic findings and vascular pathology does not necessarily follow a linear correlation, it is clear that advanced vascular pathology is usually found in patients more than 1 year of age with high resistance to pulmonary perfusion. A possible explanation for grading a biopsy as Heath-Edwards I (ie, medial hypertrophy only), in a patient with Rp/Rs greater than 1.0, is that the biopsy did not include preacinar vessels that are required to diagnose advanced morphological alterations such as plexiform lesions [5]. Although we agree with the authors that open lung biopsy gives valuable information for therapeutic options in patients with pulmonary hypertension, it remains an invasive procedure. The results of open lung biopsy should always be interpreted by taking into account the hemodynamic findings and the age of the patient.[2]

References

1. Jaklitsch M.T., Linden B.C., Braunlin E.A., Bolman R.M., III, Foker J.E. Open lung biopsy guides therapy in children. Ann Thorac Surg 2001;71:1779-1785.[Abstract/Free Full Text]
2. Heath D., Helmholz H.F., Jr, Burchell H.B., DuShane J.W., Kirklin J.W., Edwards J.E. Relation between structural changes in the small pulmonary arteries and the immediate reversibility of pulmonary hypertension following closure of ventricular and atrial septal defects. Circulation 1958;18:1167-1174.[Medline]
3. Rich S., Dantzker D.R., Ayres S.M., et al. Primary pulmonary hypertension. A national prospective study. Ann Intern Med 1987;107:216-223.
4. Gorenflo M., Vogel M., Hetzer R., et al. Morphometric techniques in the evaluation of pulmonary vascular changes due to congenital heart disease. Pathol Res Pract 1996;192:107-116.[Medline]
5. Haworth S.G. Pulmonary hypertension in childhood. Eur Respir J 1993;6:1037-1043.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gorenflo, M. Search for Related Content PubMed Articles by Gorenflo, M. Related Collections Congenital - acyanotic