A patient who died after surgery for critical mitral stenosis was found to have underlying unrecognised plexogenic pulmonary arteriopathy and familial pulmonary hypertension. The importance of recognising familial pulmonary hypertension is discussed, together with the contribution of genetic and other risk factors to plexogenic pulmonary arteriopathy. (Thorax 2000;55:247-248) Keywords: plexogenic pulmonary arteriopathy; mitral stenosis; familial pulmonary hypertension; primary pulmonary hypertension Plexogenic pulmonary arteriopathy with the formation of plexiform lesions is common in primary pulmonary hypertension and secondary pulmonary hypertension resulting from left-to-right intracardiac shunts, HIV disease, and anorexigen use.