27 thoracoscopically guided biopsies of the lung in 24 immunologically compromised children with pulmonary infiltrates. The diagnostic yield in this small series is impressive, although the attendant complications cannot be ignored. The "advantages" of doing this sort of procedure without control of the airway in patients under anesthesia with a respiratory depressant (fentanyl) who are in respiratory distress are questionable. Furthermore, although the benefits to be derived from a precise diagnosis must always be weighed against the risks imposed by the procedure, it would seem wise to anticipate serious hemorrhage in patients with abnormal clotting profiles (a common situation in the immunologically compromised). Transbronchial bite biopsy via the fiberoptic bronchoscope was probably possible in at least nine of the patients and aspiration biopsy in all. As these are simpler procedures and in combination probably yield essentially the same information, the question must be asked, "What does the thoracoscopic procedure offer that is unique?" Certainly, the reliability of aspiration biopsy in infective processes is high, and trans bronchial bite biopsy and brushings provide histologic and cytologic specimens that are comparable in quality to those obtained by the thoracoscopic procedure. These observations are not intended to decry the use of thoracoscopic examination, but only to raise a question as to its ultimate role in our diagnostic toolkit. The greatest advantage offered by the technique is that good specimens can apparently be obtained from selected, directly visualized abnormal areas of pulmonary surface. Many centers now offer a full range of diagnostic techniques, and readers of Chest will look forward with interest to reports comparing yield, morbidity, and mortality among the various procedures. At the moment, it is my impression that aspiration biopsy and trans bronchial bite biopsy with washings and brushing biopsy provide an answer in most cases of diffuse infiltrate in the immunologically compromised host. SmaIl children pose a special problem, and it may be in this area, as well as in patients with specific pleural disease, that the thoracoscopic procedure will prove most useful. In the meanwhile, until the relative merits of all of these procedures can be assessed, it probably behooves chest physicians and surgeons to remain familiar with all techniques for sampling pulmonary tissue, so that the simplest and most direct one can be selected for a given clinical problem. E. Gamer King, M.D., F.C.C.P.· Edmonton, Alberta °Division of Pulmonary and Critical Care Medicine, University of Alberta.

112 EDITORIALS

REFERENCES 1 Swierenga J, Wagenaar JPM, Bergstein PGM: The value of thoracoscopy in the diagnosis and treatment of disease affecting the pleura and lung. Pneumonologie 151:11-18, 1974 2 Canto A, Blasco E, Casillas M, et al: Thoracoscopy in the diagnosis of pleural effusion. Thorax 32:550-554, 1977 3 DeCamp RT, Moseley PW, Scott ML, et al: Diagnostic thoracoscopy. Ann Thorac Surg 16:79-84, 1973 4 Ash SR, Manfredi F: Directed biopsy using a small endoscope. N Engl J Med 291:1398-1399, 1974 5 Gwin E, Pierce G, Boggan M, et al: Pleuroseopy and pleural biopsy with the flexible fiberoptic bronchoscope. Chest et :527-531, 1975 6 Ben-Isaac FE, Simmons DB: Flexible fiberoptic pleurascopy: Pleural and lung biopsy. Chest ffl :573-576, 1975 7 Radigan LR, Glover JL: Thoracoscopy. Surgery 8 :425­ 428, 1977

Mitral Commissurotomy A Perspective a report of importance not only to surgeons, I nMontoya and co-workers in this issue (see page

131) add their extensive experience to the growing body of literature in support of open mitral commissurotomy as the preferred surgical approach for mitral stenosis. An interesting sidelight on this technical debate is that it will be self-limited, since closed commissurotomy is rarely taught now. Among other reasons, one cannot entrust to a trainee the responsibility for the blind opening thrust as readily as one can delegate and guide an open commissurotomy. Thus, in the next generation of surgeons, closed commissurotomy will be a rare skill. The relevance of this report for all chest physicians lies not in its clarification of a technical issue, however, but in its implications regarding the timing of operation for symptomatic patients. Because successful surgery for mitral valvular disease was the first modem intracardiac operation, beginning with Bailey's! report of closed commissurotomy in this very journal in 1949, most physicians who manage patients with mitral disease are all too aware of the mortality and morbidity that accompanied commissurotomy in its early years. Consequently, the common indications for commissurotomy have remained similar to those for mitral valvular replacement, te, disabling symptoms (New York Heart Association's [NYHA] functional class 3) or repeated systemic emboli. Furthermore, as with the study by Montoya et al, most other surgical reports have focused attention on the technical conflict between

CHEST, 75: 2, FEBRUARY, 1979

proponents of open vs closed commissurotomy and have therefore not quarreled with the accepted indications for operation. In my view, a careful reading of the report by Montoya et al and of other recent similar reports gives reason for suggesting a more aggressive approach to mitral stenosis. It is my belief that open mitral commissurotomy should now be offered to symptomatic patients with pure mitral stenosis who are unable to function in NYHA class 1 and who wish to do so. This recommendation is based on several factors: (1) the mortality of open mitral commissurotomy alone in experienced hands is 1 percent or less (one of the deaths in the report by Montoya et al was due to myocardial infarction in a patient who had coronary bypass with commissurotomy; in our report from Oregon," the only death in 100 consecutive patients was due to fulminant hemorrhagic pancreatitis; (2) nonsurgical therapy (incorrectly called conservative therapy) imposes substantial risks of emboli (18 percent in the series of Montoya et al and 13 percent in the Oregon experience"): (3) the occurrence of emboli or the finding of a left atrial thrombus at operation had no correlation with the cardiac rhythm in either report, making it difficult to decide which patients should receive anticoagulant therapy; and (4) long-term anticoagulant therapy alone poses substantial risks, with a five-year mortality that exceeds the combined surgical and late mortality for commissurotomy. Avoidance of all of these risks (systemic embolism is distinctly uncommon after surgery) I and restoration of functional capacity seem well worth the minimal surgical risk. Finally, in our report the durability of a good functional result was related to the extent of deterioration of the valvular leaflets found at operation. The debate about the best technique for performing commissurotomy should therefore not obscure the more important message of these reports; open mitral commissurotomy is a safe, controlled, and effective operation that should have more liberal indications than those for valvular replacement. If more liberal indications are adopted for commissurotomy than for valvular replacement, it will once again become important to ascertain before surgery the exact nature of the patient's mitral valvular disease. This was essential in the 1950s, when valvular replacement for mitral regurgitation was unavailable, but became less crucial after replacement became satisfactory and could be readily performed in lieu of a proposed commissurotomy. Now, with twodimensional echocardiographic studies and the standard invasive studies, it is possible to predict the likelihood of successful commissurotomy with reasonable precision. If, in a particular patient, there is J12

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residual uncertainty, the liberal indications for operation should not be applied. Lawrence I. Bonchek, M.D.· Milwaukee ·Professor and Chairman, Department of Thoracic and Cardiovascular Surgery, Medical College of Wisconsin. Reprint requests: Dr. Bonchek, 8700 Wed WUcondn Aoenue, Milwaukee 53226 REFERENCES

1 Bailey CP: The surgical treatment of mitral stenosis (mitral commissurotomy). Dis Chest 15:377-397, 1949 2 Housman LB, Bonchek LI, Lambert L, et at: Prognosis of patients after open mitral commissurotomy. J Thorac Cardiovasc Surg 73:742-745, 1977

"Low Voltage ECG" and Pericardial Effusion Practical and Conceptual Problems

A nyone dealing with large numbers of electrocar-

diograms must be aware of the myriad of problems with voltage, both high and low. While progressive changes in voltage (in either direction) carry certain implications, every clinician is aware of frequently tantalizing day-to-day R-wave fluctuations. For example, in diagnosing left ventricular hypertrophy, the unreliability of isolated voltage criteria and short-term variability of R-wave voltage are notorious. Low voltage, although pluricausal and rather common in hospitalized populations, has been a comparatively neglected phenomenon. Unverferth and colleagues (see page 157) investigated the role of low voltage in the diagnosis of pericardial effusions, including the sensitivity and specificity of this electrocardiographic datum in the diagnosis of pericardial effusion. They have employed reasonable criteria for the interpretation, "low voltage," which might well be generally adopted. In 64 patients with pericardial fluid, echocardiographic estimation of the volumes of effusions was not quantitatively related to electrocardiographic voltage; after pericardiocentesis in 22 patients, frontal-plane and precordial voltages increased only slightly. The low specificity of a "lowvoltage ECG" was confirmed in 36 other patients with low voltage, among whom only 13 had pericardial effusion by echocardiographic findings. In discussing their findings, Unverferth et al ably dealt with the relationship of low voltage to pericardial effusion. Three other considerations bear on this relationship. First, a decrease in voltage is common

EDITORIALS 113

Mitral commissurotomy; a perspective.

27 thoracoscopically guided biopsies of the lung in 24 immunologically compromised children with pulmonary infiltrates. The diagnostic yield in this s...
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