Long-term results of mitral valve surgery in patients with severe pulmonary hypertension

Pulmonary Hypertension and Operative Risk in Mitral Valve and Coronary Surgery

INTRODUCTION

Pulmonary hypertension (PHT) is a known risk factor for coronary artery bypass grafting (CABG), though less well understood for valve operations. We hypothesized PHT is associated with lower risk during mitral valve operations compared to CABG.

METHODS

Patients undergoing isolated mitral valve or CABG operations (2011-2019) in a regional Society of Thoracic Surgeons (STS) database were stratified by pulmonary artery systolic pressure (PASP). The association of PASP by procedure type was assessed by hierarchical regression modeling, adjusting for STS predicted risk scores.

RESULTS

Of the 2542 mitral and 11,059 CABG patients, the mitral population had higher mean STS risk of mortality (3.6% versus 2.4%, P < 0.0001) and median PASP (42 mmHg versus 32 mmHg, P < 0.0001). PASP was independently associated with operative mortality and major morbidity in both mitral and CABG patients. However, for mitral patients a 10-mmHg increase in PASP was associated with lower odds of morbidity (odds ratio: 1.06 versus 1.13), mortality (odds ratio: 1.11 versus 1.18) and intensive care unit time (4.3 versus 7.6 h) compared with CABG patients (interaction terms P < 0.0001). Among mitral patients, median PASP was higher in stenotic versus regurgitant disease (57 mmHg versus 40 mmHg, P < 0.0001). However, there was no differential association of PASP on morbidity or mortality (interaction terms P > 0.05).

CONCLUSIONS

Although mitral surgery patients tend to have higher preoperative pulmonary artery pressures, PHT was associated with a lower risk for mitral outcomes compared with CABG. Further research on the management and optimization of patients with PHT perioperatively is needed to improve care for these patients.

Pulmonary Hypertension as a Predictor of Early Outcomes of Mitral Valve Replacement: A Study in Rheumatic Heart Disease Patients

Aim

Mitral valve pathology in rheumatic heart disease patients is a common cause of secondary pulmonary hypertension (PH). Our aim was to evaluate pulmonary hypertension severity as a predictor of in-hospital mortality and early complications following mitral valve replacement.

Methods

A retrospective review of rheumatic heart disease patients who underwent mitral valve replacement between January 2017 and August 2020 was performed. Systolic pulmonary artery pressure (sPAP) was used to classify patients as no PH (<35 mmHg), mild PH (35-44 mmHg), moderate PH (45-59 mmHg) or severe PH (>60 mmHg). Patients subjected to additional cardiac procedures (such as aortic valve replacement and coronary artery bypass grafting) were excluded from the study sample.

Results

The study group was composed of 159 patients (mean age: 40; 73 male, 86 female) categorized as no PH (n = 32; 20.1%), mild PH (n = 14; 8.8%), moderate PH (n = 65, 40.9%) and severe PH (n = 48, 30.2%) groups. Patient demographic data and preoperative comorbidities were comparable among the four groups. Use of intraoperative and postoperative blood products was similar in all the groups. Severe PH patients had similar in-hospital mortality (4.2%; p = 0.74) as in groups with lesser degrees of pulmonary hypertension. Likewise, increasing severity of pulmonary hypertension did not confer any significant increase in early postoperative complications, namely prolonged ICU stay (10.4%; p = 0.41), prolonged ventilation (2.1%; p = 0.70), reintubation (4.2%; p = 0.90), reopening for bleeding tamponade (6.3%; p = 0.39), new-onset renal failure (6.3%; p = 0.91), postoperative stroke (4.2%; p = 0.52) or prolonged length of stay (mean: 5.6 + 2.8 days; p = 0.49).

Conclusions

Increasing severity of pulmonary hypertension does not appear to have a significant impact on in-hospital mortality or early postoperative outcomes of patients undergoing mitral valve replacement.

Impact of preoperative pulmonary arterial hypertension on early and late outcomes in patients undergoing valve surgery for rheumatic heart disease

Background and Aims

There is conflicting evidence on adverse effect of Pulmonary Arterial Hypertension (PAH) on outcomes after cardiac surgery for rheumatic heart disease (RHD). The authors studied Indian patients with RHD and preoperative PAH, who undergo cardiac surgery with a hypothesis that they have poor short and long-term outcomes.

Methods

This was a retrospective observational study of 407 patients. The patients were divided in three groups based on PAH estimated on echocardiograph as; no or mild PAH (pulmonary artery systolic pressure (PASP) <30 mm of Hg); moderate PAH (PASP 31-55 mm of Hg) and severe PAH (PASP >55 mm of Hg). The primary endpoint was in-hospital mortality and major morbidities; while secondary endpoint was long-term survival.

Results

In-hospital mortality was 24 (5.9%); and was not different in patients with severe, (9.1%), moderate (4.5%) or mild PAH (2.8%) (P = 0.09). Patients with severe PAH had higher incidence of prolonged ventilation (P = 0.007). Factors independently associated with mortality were; >2-packed cell transfusion, prolonged ventilation and acute kidney injury but not moderate and severe PAH. Patients with mitral stenosis (MS) and severe PAH had significantly higher mortality as compared to no or mild PAH (P = 0.03) on long-term follow-up [81.37% (mean duration 19.40 ± 14.10 months)], mortality was 8% and not statistically different (P = 0.25) across PAH categories.

Conclusion

Moderate and severe PAH does not affect short and long term outcomes of patients undergoing valve surgery for RHD. Patients with MS with severe PAH had higher mortality compared to those with no PAH.

Epidemiology of Pulmonary Hypertension in Left Heart Disease

Pulmonary hypertension (PH) in the setting of left side heart disease is associated with adverse outcomes. The exact prevalence of PH in the different pathologies that affect the left ventricle, however, is difficult to access with the current literature. The lack of a standard definition of PH in older studies, the different modalities to assess pulmonary artery pressures and the varying disease severity, all account for the great variability in the reported prevalence of PH. PH can accompany heart failure (HF) with reduced (HFrEF) or preserved ejection fraction (HFpEF) as well as mitral and aortic valve disease; in any of these instances it is important to recognize whether the elevation of pulmonary pressures is driven by elevated left ventricular pressures only (isolated post-capillary PH) or if there is an accompanying remodeling component in the pulmonary arterioles (combined post-capillary and pre-capillary PH). The objective of this review is to describe the definitions, prevalence and the risk factors associated with the development of PH in the setting of HFrEF, HFpEF and valvular heart disease.

Outcomes of repeat mitral valve surgery in patients with pulmonary hypertension

OBJECTIVE

We sought to study the outcomes of redo-mitral valve surgery in patients with pulmonary hypertension.

METHODS

We reviewed data on redo mitral valve surgery in patients with pulmonary hypertension measured by Swan-Ganz catheter (mean pulmonary artery pressure ≥ 25 mm Hg or systolic pulmonary artery pressure ≥ 40 mm Hg).

RESULTS

Between 1996 and 2010, 637 patients underwent 658 redo mitral valve operations; 138 of them had pulmonary hypertension. The mean patient age was 61.3 (13.9) years, with mean left ventricular ejection fraction of 47.6% (13.2%). The mean systolic pulmonary artery pressure was 61.5 (16.8) mm Hg, and mean pulmonary artery pressure was 40.8 (11.6) mm Hg. Patients had one (71%, 98/138), two (23.9%, 33/138), and three (5.1%, 7/138) previous mitral valve operations. Thirty-day mortality was 10.1% (14/138). Multivariate predictors of 30-day mortality were chronic renal failure [odds ratio (OR), 8.041; P = 0.022], peripheral vascular disease (OR, 5.976; P = 0.025), previous mitral valve replacement (OR, 9.034; P = 0.014), and increasing age (OR, 1.077; P = 0.013). The severity of pulmonary hypertension did not impact 30-day (P = 0.314) or late mortality (P = 0.860). Kaplan-Meier survival rates at 1, 3, and 5 years were 76.6% (n = 99), 65.7% (n = 62), and 55.9% (n = 41), respectively.

CONCLUSIONS

Patients with pulmonary hypertension that undergo redo mitral valve surgery have a 55.9% 5-year survival rate. Increasing age, chronic renal insufficiency, peripheral vascular disease, and preexisting mitral valve prosthesis are associated with early mortality. The severity of pulmonary hypertension does not affect operative mortality rates, but it may decrease 1-, 3-, and 5-year survival.

An excellent result of surgical treatment in patients with severe pulmonary arterial hypertension following mitral valve disease

Objective

Observe the efficacy of surgical treatment in patients with severe pulmonary arterial hypertension caused by mitral valve disease.

Methods

We examined the results of surgical treatment in 32 patients with mitral valve disease and severe pulmonary arterial hypertension (pulmonary arterial systolic pressure ≥ 80 mmHg) retrospectively. Operative and postoperative data collection included type of the surgery, cardiopulmonary bypass time, cross-clamp time and the mortality rate. Pulmonary arterial systolic pressure, left atrial diameter, left ventricular end-diastolic diameter, and left ventricular ejection fraction were recorded and compared.

Results

A total number of 32 patients had the operation of mitral valve replacement. Among those subjects, twenty-seven patients were surgically replaced with mechanical prosthesis and five patients with tissue prosthesis. Only one patient died of pneumonia, with a mortality rate of 3.1 %. The statistical results of preoperative and postoperative echocardiographic data showed significant decrease in pulmonary arterial systolic pressure (101.2 ± 20.3 versus 48.1 ± 14.3 mmHg, P < 0.05), left atrial diameter(67.6 ± 15.7 versus 54.4 ± 11.4 mm, P < 0.05) and left ventricular end-diastolic diameter (52.3 ± 9.5 versus 49.2 ± 5.9 mm, P < 0.05). There was no significant change in left ventricular ejection fraction (59.2 ± 6.5 versus 57.9 ± 7.6, P = NS). At the time of follow-up, twenty-eight (96.6 %) patients were classified in New York Heart Association functional class I or II, one(3.4 %) in class III, with the mortality rate is zero percent.

Conclusions

Mitral valve replacement can be performed successfully in patients with mitral valve disease and severe pulmonary arterial hypertension with an acceptable perioperative risk.

Rest and exercise hemodynamics before and after valve replacement--a combined Doppler/catheter study

BACKGROUND

Hemodynamic improvement is a common finding following valve replacement. However, despite a normally functioning prosthesis and normal left ventricular ejection fraction, some patients may show an abnormal hemodynamic response to exercise.

METHODS

In a combined catheter/Doppler study, rest and exercise hemodynamics were evaluated in 23 patients following aortic (n = 12) (Group 1) or mitral valve (n = 11) (Group 2) replacement and compared with preoperative findings. Patient selection was based on absence of coronary artery disease and left ventricular failure as shown by preoperative angiography. Cardiac output, pulmonary artery pressure, pulmonary capillary pressure, and pulmonary resistance were measured by right heart catheterization, whereas the gradient across the valve prosthesis was determined by Doppler echocardiography. Postoperative evaluation was done at rest and during exercise. The mean follow-up was 8.2 +/- 2.2 years in Group 1 and 4.2 +/- 1 years in Group 2.

RESULTS

With exercise, there was a significant rise in cardiac output in both groups. In Group 1, mean pulmonary pressure/capillary pressure decreased from 24 +/- 9/18 +/- 9 mmHg preoperatively to 18 +/- 2/12 +/- 4 mmHg postoperatively (p < 0.05), and increased to 43 +/- 12/30 +/- 8 mmHg with exercise (p < 0.05). The corresponding values for Group 2 were 36 +/- 12/24 +/- 6 mmHg preoperatively, 24 +/- 7/17 +/- 6 mmHg postoperatively (p < 0.05), and 51 +/- 2/38 +/- 4 mmHg with exercise (p < 0.05). Pulmonary vascular resistance was 109 +/- 56 dyne.s.cm-5 preoperatively, 70 +/- 39 dyne.s.cm-5 postoperatively (p < 0.05), and 70 +/- 36 dyne.s.cm-5 with exercise in Group 1. The corresponding values for Group 2 were 241 +/- 155 dyne.s.cm-5, 116 +/- 39 dyne.s.cm-5 (p < 0.05), and 104 +/- 47 dyne.s.cm-5. There was a significant increase in the gradients across the valve prosthesis in both groups, showing a significant correlation between the gradient at rest and exercise. No correlation was found between valve prosthesis gradient and pulmonary pressures.

CONCLUSION

Exercise-induced pulmonary hypertension and abnormal left ventricular filling pressures seem to be a frequent finding following aortic or mitral valve replacement. Both hemodynamic abnormalities seem not to be determined by obstruction to flow across the valve prosthesis and may be concealed, showing nearly normal values at rest but a pathologic response to physical stress.

Mitral valve replacement in severe pulmonary arterial hypertension

The immediate postoperative hemodynamics in 43 patients with severe pulmonary arterial hypertension who underwent mitral valve replacement between January 2000 and September 2001 were studied prospectively. The mean age was 30.6 years. There was mitral stenosis in 19 (44.1%), mitral regurgitation in 9 (20.9%), and mixed lesions in 15 (34.9%). In 36 patients (83.7%, group 1) pulmonary arterial pressure was sub-systemic, with a mean of 58.1 mm Hg and pulmonary vascular resistance of 743.4 dyne x s x cm(-5). Seven patients (16.3%, group 2) had supra-systemic pulmonary arterial pressure of 83.2 mm Hg and pulmonary vascular resistance of 1,529 dyne x s x cm(-5). Lung biopsies were taken from the right lower lobe in 24 patients. Operative mortality was 5.5% in group 1 and 28.5% in group 2. After mitral valve replacement, the pulmonary arterial pressure and vascular resistance decreased significantly in group 1. In group 2, pulmonary arterial pressure decreased significantly but pulmonary vascular resistance remained elevated. Pulmonary vascular changes did not progress beyond grade III (Heath-Edwards' classification). Mitral valve replacement is safe even in the presence of severe pulmonary arterial hypertension as long as pulmonary arterial pressures are below systemic pressures. Lung biopsy did not help in identifying patients with irreversible pulmonary arterial changes.

Hemodynamic effects of inhaled nitric oxide in women with mitral stenosis and pulmonary hypertension

Mitral stenosis (MS) is associated with elevated left atrial pressure, increased pulmonary vascular resistance (PVR), and pulmonary hypertension (PH). The hemodynamic effects of inhaled nitric oxide (NO) in adults with MS are unknown. We sought to determine the acute hemodynamic effects of inhaled NO in adults with MS and PH. Eighteen consecutive women (mean age 58 +/- 15 years) with MS and PH underwent heart catheterization. Hemodynamic measurements were recorded at baseline, after NO inhalation at 80 ppm, and after percutaneous balloon valvuloplasty (n = 10). NO reduced pulmonary artery systolic pressure (62 +/- 14 mm Hg [baseline] vs 54 +/- 15 mm Hg [NO]; p <0.001) and PVR (3.7 +/- 2.5 Wood U [baseline] vs 2.2 +/- 1.4 Wood U [NO]; p <0.001). NO had no effect on mean aortic pressure, left ventricular end-diastolic pressure, left atrial pressure, cardiac output, or systemic vascular resistance. Mitral valve area increased after valvuloplasty (0.9 +/- 0.2 cm2 [baseline] vs 1.6 +/- 0.3 cm2 [postvalvuloplasty]; p <0.001). A decrease in left atrial pressure (25 +/- 4 mm Hg [baseline] vs 17 +/- 4 mm Hg [after valvuloplasty]; p <0.001) and pulmonary artery systolic pressure (58 +/- 12 mm Hg [baseline] vs 45 +/- 8 mm Hg [after valvuloplasty]; p <0.001) was observed after valvuloplasty. No change in cardiac output or PVR was observed. Thus inhaled NO, but not balloon valvuloplasty, acutely reduced PVR in women with MS and PH. This suggests that a reversible, endothelium-dependent regulatory abnormality of vascular tone is an important mechanism of elevated PVR in MS.

As originally published in 1988: Long-term results of mitral valve surgery in patients with severe pulmonary hypertension. Updated in 1996

Mitral valve surgery was performed in 88 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure, 94.7 +/- 22 mm Hg; range, 70-180 mm Hg) over a 10-year period. Sixty-four patients (73%) were in New York Heart Association Functional Class III or IV. There were 64 valve replacements and 24 open mitral commissurotomies. Operative mortality was 5.6% (5 patients) and was not related to the degree of pulmonary hypertension, surgical procedure performed, or type of valve lesion. A 100% follow-up was obtained, ranging from nine months to 10 years, with a mean of 44 months. Six late cardiac deaths (7.2%) occurred, 5 in patients with valve replacement and 1 in a patient who underwent a commissurotomy. Actuarial survival was 86 +/- 3% at five years and 83 +/- 4% at 10 years. Fourteen patients underwent right ventricular catheterization a mean of 24 months following operation. Systolic pulmonary artery pressure had decreased from a mean preoperative value of 101 +/- 22 to 40.5 +/- 7 mm Hg (p < 0.001). Cardiac index increased by 55% of the preoperative values. Functional status improved markedly; 71 survivors (93%) were in New York Heart Association Class I or II. These results indicate that, in patients with mitral valve lesions and severe pulmonary hypertension, (1) surgical procedures can be performed with an acceptable operative mortality; (2) excellent long-term survival and functional results can be obtained; and (3) pulmonary hypertension decreases significantly after operation. Patients with mitral valve disease may benefit from surgical treatment regardless of the degree of pulmonary hypertension.

Impact of respiratory acid-base status in patients with pulmonary hypertension

BACKGROUND

The perioperative management of patients undergoing mitral valve replacement (MVR) with pulmonary hypertension from mitral stenosis may be complicated by increased pulmonary vascular resistance. The purpose of this study was to examine the influence of respiratory acid-base status on the pulmonary hemodynamic indices of patients with pulmonary hypertension before and after MVR.

METHODS

Ten patients with pulmonary hypertension from mitral stenosis (mean preoperative systolic pulmonary artery pressure, 73 +/- 8 mm Hg) undergoing MVR were studied in the operating room before and after MVR. Arterial partial pressure of carbon dioxide was manipulated by the addition of 5% carbon dioxide to the breathing circuit. Hemodynamic data were collected as the partial pressure of carbon dioxide rose from 30 mm Hg to 50 mm Hg and decreased back to 30 mm Hg.

RESULTS

There were no differences in mean pulmonary artery pressure or pulmonary vascular resistance before and after MVR. Before MVR, mean pulmonary artery pressure increased from 32 +/- 1 mm Hg to 48 +/- 1 mm Hg as the partial pressure of carbon dioxide rose from 30 mm Hg to 50 mm Hg (p < 0.05), and pulmonary vascular resistance rose from 379 +/- 30 to 735 +/- 40 dynes.second.cm-5 (p < 0.05). These effects on mean pulmonary artery pressure and pulmonary vascular resistance were not different after MVR.

CONCLUSION

Respiratory acid-base status has a profound impact upon pulmonary vascular resistance in patients with pulmonary hypertension from mitral stenosis undergoing MVR. This impact persists in the immediate postoperative period. We conclude that respiratory acidemia should be avoided in these patients, whereas respiratory alkalemia may be used to help minimize pulmonary vascular resistance.

Immediate and long-term effect of mitral balloon valvotomy on severe pulmonary hypertension in patients with mitral stenosis

The pulmonary vascular hemodynamics were studied in 21 patients with severe mitral stenosis and severe pulmonary hypertension. Hemodynamic data were obtained before and immediately after mitral balloon valvotomy (MBV) and at follow-up 7 to 14 months (mean 12 months) later by repeat catheterization. The mean pulmonary capillary wedge pressure (PCW) decreased from 27 +/- 5 to 15 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 18 +/- 4 to 6 +/- 2 mm Hg (p < 0.001). Mitral valve area (MVA) increased from 0.6 +/- 0.1 to 1.5 +/- 0.3 cm2 (p < 0.02). Cardiac index increased from 2.2 +/- 0.3 to 2.6 to 0.5 L/min/m2 (p < 0.02). The pulmonary artery systolic pressure decreased from 65 +/- 13 to 50 +/- 13 mm Hg (p < 0.001), and no significant change was seen in pulmonary vascular resistance (PVR) immediately after MBV from 461 +/- 149 to 401 +/- 227 dynes/sec/cm(-5) (p = 0.02). At follow-up the MVA increased from 1.5 +/- 0.3 to 1.7 +/- 0.3 cm2 (p < 0.02). Cardiac index increased further to 3 +/- 0.4 L/min/m2 (p < 0.02). MVG and PCW pressure remained the same. The pulmonary artery systolic pressure decreased further to 38 +/- 9 mm Hg (p < 0.02). PVR decreased significantly to 212 +/- 99 dynes/sec/cm(-5) (p < 0.02). We concluded that the pulmonary artery pressure decreased without normalizing immediately after MBV and normalized in patients with optimal results from mitral balloon valvotomy 7 to 14 months later. Insignificant change in PVR was seen immediately after MBV and markedly decreased or normalized at late follow-up in patients with optimal result from MBV.

Balloon mitral valvotomy in patients with systemic and suprasystemic pulmonary artery pressures

Mitral stenosis with severe pulmonary artery hypertension constitutes a high risk subset for surgical commissurotomy or valve replacement. Balloon mitral valvotomy has been proposed as a technique for treating high risk surgical patients with mitral stenosis. The efficacy of this technique in patients with severe pulmonary artery hypertension, however, has not been fully evaluated. Percutaneous transvenous mitral commissurotomy (PTMC) was performed in 450 consecutive patients. Of these, forty-five (10%) patients had systemic or suprasystemic systolic pulmonary artery pressures (110 +/- 20, range 96 to 170 mm Hg). The baseline characteristics and immediate hemodynamic results of these 45 patients with systemic/suprasystemic systolic pulmonary artery pressures (group I) were analysed and compared with those of 405 patients with subsystemic systolic pulmonary artery pressures (group II). Patients in group I were more symptomatic (New York Heart Association functional class > or = III, 96 vs. 55%, P < 0.001) and had severe subvalvular fibrosis (mitral subvalvular distance ratio [MSDR], 0.14 +/- 0.04 vs. 0.22 +/- 0.04, P < 0.01). Before PTMC, mean transmitral gradient was higher (34 +/- 8 vs. 25 +/- 4 mm Hg, P < 0.02) and mitral valve area smaller (0.5 +/- 0.3 vs. 0.9 +/- 0.4 cm2, P < 0.02) in group I patients, who also had higher pulmonary vascular resistance (16 +/- 5 vs. 9 +/- 5 U, P < 0.005). After PTMC final mean transmitral gradients (7 +/- 3 vs. 5 +/- 3 mm Hg) and mitral valve areas (1.9 +/- 0.4 vs. 2.0 +/- 0.4 cm2) were similar in both groups (P = NS). Group I patients had a greater decrease in pulmonary artery pressures (34 +/- 4 vs. 25 +/- 2%, P < 0.05) but final systolic pulmonary artery pressures (82 +/- 20 vs. 50 +/- 14 mm Hg) and pulmonary vascular resistance (12 +/- 4 vs. 6 +/- 4 U) remained significantly higher in this group (P < 0.005). Thus, in patients with severe pulmonary artery hypertension, PTMC is a safe and effective technique providing good immediate hemodynamic results.

Long-term outcome of cardiac surgery in patients with mitral stenosis and severe pulmonary hypertension

BACKGROUND

Pulmonary hypertension increases perioperative risk in patients having mitral valve replacement, but most studies have included patients with mixed mitral valve disease and have not examined long-term outcome.

METHODS AND RESULTS

We retrospectively examined the results and predictors of outcome of cardiac surgery in 43 patients (age, 62 +/- 13 years [mean +/- SD]; 81% women) with a primary diagnosis of mitral stenosis and severe pulmonary hypertension (pulmonary artery systolic pressure > or = 60 mm Hg or mean pressure > or = 50 mm Hg). Patients with more than mild mitral regurgitation were excluded. Thirty-eight patients (88%) were in NYHA functional class III or IV, and 11 patients (26%) had an acute presentation requiring urgent surgery. Preoperative hemodynamics demonstrated a mean mitral valve area of 0.7 +/- 0.3 cm2, mean pulmonary artery pressure of 50 +/- 9 mm Hg, and pulmonary artery systolic pressure of 81 +/- 18 mm Hg. Other characteristics included right ventricular failure (18 patients), coronary artery disease (16 patients), and critical aortic stenosis (11 patients). Forty patients underwent mitral valve replacement with St Jude prostheses; 3 had open commissurotomy. Additional surgical procedures included aortic valve replacement (42%), coronary artery bypass graft surgery (26%), and tricuspid valvuloplasty (16%). There were 5 perioperative deaths (11.6%), and 7 other patients (16%) had major complications, including reoperation for hemorrhage, stroke, respiratory failure, myocardial infarction, or a > 30-day hospitalization. Univariate analysis of demographic, hemodynamic, and operative characteristics identified the following predictors of perioperative death (P < .05): acute presentation, clinical evidence of right ventricular failure, impaired left ventricular ejection fraction, and increased left ventricular diastolic pressure. Predictors of complications (P < .05) were acute presentation, ECG evidence of right ventricular hypertrophy, and elevated right ventricular systolic pressure. Multivariate analysis showed only acute presentation and right ventricular hypertrophy as predictors of perioperative death or major complications, respectively. Five- and 10-year actuarial survivals were 80% and 64%, respectively. The only predictor of long-term mortality was advanced age. Functional NYHA status was improved by one grade or more in 76% of survivors.

CONCLUSIONS

Patients referred to a tertiary care hospital in the United States with mitral stenosis and severe pulmonary hypertension often have other associated cardiac diseases and comorbid conditions. Cardiac surgery can be successfully performed with an acceptable mortality, and risk factors for poor perioperative outcome can be identified by preoperative clinical characteristics. Younger patients have the best long-term survival, and most survivors experienced long-term improvement in functional status.

Pulmonary factors limiting exercise capacity in patients with heart failure

Patients with heart failure are frequently limited by exertional dyspnea. The mechanisms underlying dyspnea in these patients remain unclear. In this review, the pathologic changes that occur in the lung as a consequence of chronic pulmonary venous hypertension, pulmonary function test abnormalities, and potential mechanisms for dyspnea including airflow obstruction and/or respiratory muscle dysfunction are discussed.

Prognostic significance of changes in the compliance of the pulmonary venous system after isosorbiddinitrate in patients with mitral stenosis

It is agreed that a stiff pulmonary venous bed can cause severe pulmonary hypertension. This condition can also influence the clinical and hemodynamic outcome of mitral valve replacement (MVR). This study has been aimed at assessing whether changes in the pulmonary venous compliance (PVcomp) after application of isosorbiddinitrate (ISDN) can be of prognostic value in patients 6 months after MVR. PVcomp was calculated according to the Hirakawa equation in 34 patients with isolated mitral stenosis (MS) before and after ISDN. In 19 patients (group I) there was an increase of PVcomp by more than 15% (5.3 vs. 8.1 ml/mmHg), while 15 patients (group II) showed no differences in PVcomp after ISDN, despite the significant decrease in PAP and PWP in both groups (measured with the use of Swan-Ganz thermodilution catheters). Six months after MVR a significant decrease in PAP, PWP, PVR and an increase in SVI was observed in both groups during rest. During effort (25 W), significant increases in PAP and PWP were recorded in most of patients from the group II, as opposed to group I. It is concluded that significant increase in PVcomp after ISDN in patients with MS can be a prognostic of good clinical results 6 months after MVR.

Percutaneous mitral valvuloplasty with severe pulmonary artery hypertension

The aim of this study was to assess the initial and midterm outcome of patients with severe pulmonary hypertension undergoing percutaneous mitral valvuloplasty (PMV). Accordingly, the baseline characteristics, immediate results and follow-up of 64 consecutive patients with severe pulmonary artery hypertension (systolic pulmonary artery pressure > or = 60 mm Hg on cardiac catheterization) (group I) were analyzed and compared with those of 194 consecutive patients with lower pulmonary pressures (group II). Patients in group I were more symptomatic (New York Heart Association functional class > or = III, 72 vs 40%, p < 0.001) and had higher echocardiographic scores (8.6 +/- 2 vs 7.4 +/- 1, p < 0.05). Before PMV, mitral gradient was higher (17 +/- 6 vs 13 +/- 5 mm Hg, p < 0.025) and mitral valve area smaller (0.79 +/- 0.2 vs 0.96 +/- 0.2 cm2, p < 0.005) in group I patients, who also had higher pulmonary vascular resistances (469 +/- 299 vs 157 +/- 125 dynes s-1 cm-5, p < 0.005). On multivariate analysis patients in group I were more symptomatic, had smaller mitral valve areas and higher mitral gradients. PMV success (area gain > 50% without complications) was similar (89 vs 87%) in both groups. After PMV final mitral gradient (5 +/- 2 vs 4 +/- 2 mm Hg) and area (1.82 +/- 0.5 vs 1.87 +/- 0.5 cm2) were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical mitral stenosis causing ischemic hepatic failure. Successful treatment by percutaneous balloon mitral valvotomy

We report a 52-year-old patient with severe mitral stenosis who developed new onset atrial fibrillation, low output congestive heart failure and fulminant ischemic hepatic failure with subsequent severe coagulopathy. Percutaneous mitral valvotomy resulted in dramatic clinical improvement with complete resolution of liver function. This case illustrates the potential life-saving role for percutaneous balloon mitral valvotomy in treating critically ill patients who are unable to undergo thoracotomy due to coexisting medical illness.

Percutaneous mitral valvuloplasty in surgical high risk patients

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age greater than 70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction less than or equal to 35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 +/- 11 versus 49 +/- 12 years; p = 0.0001) and echocardiographic score (9.4 +/- 1.8 versus 8.2 +/- 1.5; p = 0.005) were higher, whereas cardiac output (2.9 +/- 0.9 versus 4.1 +/- 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 +/- 0.4 versus 1.1 +/- 0.3 mm2; p = 0.002) were lower. Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Reversibility of pulmonary artery hypertension in aortic stenosis after aortic valve replacement

Fifty-two surgical patients with isolated aortic valve stenosis were studied preoperatively and postoperatively to determine the incidence of pulmonary hypertension and its response to surgical intervention. Pulmonary artery systolic hypertension was classified as absent (group 1, less than 30 mm Hg), mild (group 2, 30 to 39 mm Hg), moderate (group 3, 40 to 59 mm Hg), and severe (group 4, greater than 60 mm Hg). Thirty-seven of our patients (71%) had preoperative pulmonary hypertension. There was a positive correlation between left ventricular end-diastolic pressure and both systolic and diastolic pulmonary artery pressures preoperatively (p less than 0.001). After operation we found a decrease in mean systolic pulmonary pressure in group 4, from 85.8 +/- 23 mm Hg to 41.2 +/- 10.4 mm Hg (a 52% decrease, p less than 0.001), and in group 3, from 48.9 +/- 5.9 mm Hg to 32.1 +/- 7.1 mm Hg (a 34% decrease, p less than 0.001). A significant decrease in the mean diastolic pressure was found only in group 4, in which the pressure decreased from 33.7 +/- 8.7 mm Hg to 26.0 +/- 7.6 mm Hg (p less than 0.05). The operative mortality was 1.9%. Our data indicate that pulmonary artery hypertension in aortic stenosis is common, is related to end-diastolic pressure, and can be expected to improve in the early postoperative period.

Progressive improvement in pulmonary vascular resistance after percutaneous mitral valvuloplasty

Percutaneous mitral valvuloplasty has been proposed as a nonsurgical technique for treating high-risk patients with mitral stenosis who are deferred from mitral valve replacement. The effect of this technique on patients with pulmonary hypertension, however, has not been fully evaluated. Accordingly, serial assessment of pulmonary vascular resistance was made in 14 patients with critical mitral stenosis and pulmonary hypertension (pulmonary vascular resistance greater than 250 dynes.sec/cm5 or mean pulmonary artery pressure greater than 40 mm Hg or both) who underwent percutaneous balloon dilatation of the mitral valve. Balloon valvuloplasty was performed with either one (n = 10) or two (n = 4) balloons through the transseptal approach, and it resulted in significant improvement in mean mitral gradient (from 18 +/- 4 to 9 +/- 4 mm Hg, p less than 0.001), systemic blood flow (from 3.7 +/- 1.2 to 5.0 +/- 2.2 l/min, p less than 0.001), and calculated mitral valve area (from 0.7 +/- 0.2 to 1.6 +/- 0.7 cm2, p less than 0.001). Immediately after balloon mitral valvuloplasty, pulmonary vascular resistance fell from 630 +/- 570 to 447 +/- 324 dynes.sec/cm5. Repeat catheterization 7 +/- 4 months after valvuloplasty showed further improvement of pulmonary hypertension in 12 of the 14 patients, with a mean pulmonary vascular resistance for the group as a whole of 280 +/- 183 dynes.sec/cm5, p less than 0.005. In two patients, mitral valve restenosis to a mitral valve area less than 1.0 cm2 was associated with a return of pulmonary hypertension to predilatation values.(ABSTRACT TRUNCATED AT 250 WORDS)