Ann Thorac Surg 2006;81:213
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Emile A. Bacha, MD
Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115
(Email: emile.bacha{at}cardio.chboston.org).
The present article by Sachweh and colleagues [1] is important because it is a rare series of adult atrial septal defect (ASD) patients that were worked up and studied in a systematic manner at a single institution using preoperative catheterization and lung biopsy at the time of repair in all patients. This allowed the authors to perform some valid, albeit retrospective, analysis of a problem that is not hugely prevalent, but is nevertheless encountered with some frequency by most heart surgeons. When confronted with an adult ASD patient with an elevated pulmonary artery (PA) pressure, the following questions arise: is surgery safe and at what level of PA pressure and pulmonary vascular resistance? Such a patient should be evaluated for device closure, given that one can temporarily balloon occlude the ASD and observe hemodynamics and the effect of cardiopulmonary bypass on hypertensive lungs is avoided. Assuming the patient is not a candidate for device closure, there are no clear-cut current guidelines that can guide surgical decision-making. Unfortunately, although the present study is very instructive, it still leaves the clinician with no definitive answer to the previously posed question.
An important statement of this article is the sentence that states: "Preoperative hemodynamic data do not predict the degree of hypertensive pulmonary vascular disease (HPVD) in lung biopsy specimens." Other criteria that did not influence development of HPVD were defect size and age of the patient. Indeed, the mean Qp/Qs in group III (those with histologic changes considered irreversible) was 2.9. Of course, as acknowledged by the authors, a major limitation is that lesions may be irregularly distributed among the lung segments; thus a lung biopsy will not be representative of the entire lung. Nevertheless this suggests that we have much to learn yet about what causes HPVD and why certain patients have HPVD develop at a younger age and why others do not.
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References
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- Sachweh JS, Daebritz SH, Hermanns B, et al. Hypertensive pulmonary vascular disease in adults with secundum or sinus venosus atrial septal defect Ann Thorac Surg 2006;81:207-213.[Abstract/Free Full Text]
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