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Correspondence |

Pulmonary Graft Dysfunction and Elevated Pulmonary PressuresPulmonary Graft Dysfunction and Pulmonary Pressure FREE TO VIEW

Christopher Jenks, MD; Askin Uysal, MD; for the Lung Transplant Outcomes Group
Author and Funding Information

From the Department of Medicine and Pediatrics (Dr Jenks) and the Department of Pulmonary and Critical Care (Dr Uysal), Louisiana State University.

Correspondence to: Christopher Jenks, MD, 1501 Kings Highway, Shreveport, LA 71103; e-mail: cjenks@lsuhsc.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(3):826-827. doi:10.1378/chest.11-0682
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To the Editor:

In a recent study, Fang and colleagues1 brought up some interesting points concerning elevated pulmonary pressures (ie, mean pulmonary arterial pressure [mPAP]) and primary graft dysfunction (PGD). In their study, they propose that elevated pulmonary pressures are associated with the development of PGD.

We congratulate the authors on their hard work and success. However, we do have some concerns:

  • The authors do not clearly define their cutoff for elevated pulmonary pressure. According to the American College of Chest Physicians,2 most experts generally accept elevated pulmonary pressures to be an mPAP > 25 mm Hg with a pulmonary capillary or left atrial pressure < 15 mm Hg. The authors have a wide range of elevated pulmonary pressures for both the PGD and the non-PGD groups (38.5 ± 16.3 mm Hg and 29.6 ± 11.5 mm Hg, respectively). By the current American College of Chest Physicians standard of elevated pulmonary pressures, some patients might not even technically meet the criteria for pulmonary hypertension.

  • The authors fail to definitively demonstrate the type of pulmonary hypertension. Although they report that pulmonary hypertension was due to idiopathic pulmonary fibrosis, which would generally place the patients into class 3, the readers are forced to assume this information.

  • There is possible misclassification of pulmonary hypertension. In an elegant study, Halpern and Taichman3 demonstrated that many patients with a diagnosis of pulmonary arterial hypertension were misclassified and should have been classified with pulmonary venous hypertension (about one-half the patients in their study were misclassified).

  • There is no mention as to whether the patients were treated for pulmonary hypertension.

  • There is no mention as to whether the patients had a history of controlled or uncontrolled hypertension. Pulmonary hypertension has many causes, and suboptimal control of hypertension can cause elevated pulmonary pressures (class 2 pulmonary hypertension).

  • There were differences in pulmonary pressures during surgery. The patients did not necessarily have a preoperative placement of the pulmonary arterial catheter. Pulmonary pressures can vary with volume resuscitation, intubation, type of mechanical ventilation, sedation, and so forth. The authors do acknowledge this limitation but still go on to state definitively that the lack of these data did not confound the relationship of the mPAP with PGD.

A reproduction of this study, correcting for the above concerns, would add significant value to the current literature. This would then allow clinicians to accurately assess risk factors for PGD in this instance and to counsel patients on the potential complications.

Fang S, Studer S, Kawut SM, et al; for the Lung Transplant Outcomes Group for the Lung Transplant Outcomes Group Elevated pulmonary artery pressure is a risk factor for primary graft dysfunction following lung transplantation for idiopathic pulmonary fibrosis. Chest. 2011;1394:782-787 [CrossRef] [PubMed]
 
Rubin LJ.American College of Chest PhysiciansRubin LJ. American College of Chest Physicians Diagnosis and management of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126suppl 1:7S-10S [CrossRef] [PubMed]
 
Halpern SD, Taichman DB. Misclassification of pulmonary hypertension due to reliance on pulmonary capillary wedge pressure rather than left ventricular end-diastolic pressure. Chest. 2009;1361:37-43 [CrossRef] [PubMed]
 

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References

Fang S, Studer S, Kawut SM, et al; for the Lung Transplant Outcomes Group for the Lung Transplant Outcomes Group Elevated pulmonary artery pressure is a risk factor for primary graft dysfunction following lung transplantation for idiopathic pulmonary fibrosis. Chest. 2011;1394:782-787 [CrossRef] [PubMed]
 
Rubin LJ.American College of Chest PhysiciansRubin LJ. American College of Chest Physicians Diagnosis and management of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126suppl 1:7S-10S [CrossRef] [PubMed]
 
Halpern SD, Taichman DB. Misclassification of pulmonary hypertension due to reliance on pulmonary capillary wedge pressure rather than left ventricular end-diastolic pressure. Chest. 2009;1361:37-43 [CrossRef] [PubMed]
 
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