I read with great interest the case report by Langlebenet al 1 of a woman with coexisting mitral stenosis and primary pulmonary hypertension (PPH) or plexogenic pulmonary arteriopathy who succumbed to operation for relief of her mitral stenosis. The failure of the patient's pulmonary hypertension to decrease postoperatively led to her fatal outcome because the coexisting primary pulmonary hypertension was not recognised preoperatively.

I would like to call attention to the fact that the diagnosis should have been suspected preoperatively because her pulmonary artery wedge pressure was only modestly raised (16 mm Hg; normal = 12) and her pulmonary vascular resistance was extremely high (1823 dynes s cm^–5; normal = 67 (30)). In the presence of severe mitral stenosis the pulmonary …