Persistent pulmonary hypertension after mitral valve surgery is related to post-operative adverse in-hospital events and mortality.
R Heijting, R Lindhout, P Klein, R J M Klautz, P R Tuinman, S Eberl, A Vonk Noordegraaf, F W Asselbergs, A F Schmidt, M C Van De VeerdonkAbstract
Background/Introduction
Primary mitral valve regurgitation (MR) is a prevalent disease and when left untreated associated with a poor prognosis. Pulmonary hypertension (PH) is a common complication of MR. In patients with severe MR, severe PH, defined as the estimated systolic pulmonary artery pressure (eSPAP) by echocardiography >52mmHg is an indication for mitral valve surgery. But even mild pre-operative PH (eSPAP >34mmHg) is associated with increased mortality. Few old or smaller studies suggested that despite surgical intervention, PH may persist. But the predictors and outcomes of post-operative PH have not been sufficiently investigated.
Purpose
The aim of this study is to determine the prevalence, determinants and outcomes of post-operative PH in patients that underwent elective mitral valve surgery because of severe primary MR.
Methods
We enrolled patients with severe primary MR who underwent elective mitral valve surgery at two university medical centres between 1 January 2016 and 1 April 2025. The study was approved by the Medical Ethical Committee. Before - and 4 days post-surgery, PH was evaluated on transthoracic echocardiography using the peak tricuspid regurgitation velocity (TRV)-signal to calculate the eSPAP (esPAP = 4 x peak TRV2). The primary endpoint was all-cause mortality. The secondary endpoint was a combined endpoint of post-operative in-hospital adverse events. Predictors of post-operative PH were evaluated using logistic regression analyses, survival estimates were calculated using Cox regression.
Results
417 patients were included (mean age 65±12 years; 39% (164) patients were female). Mitral valve repair was performed in 76% (316) patients, mitral valve replacement in 24% (101) patients and 42% (175) patients underwent concomitant tricuspid valve repair. The prevalence of pre-operative PH was 55% (229/417) (mean eSPAP 45±9mmHg). In 45% (189/417) patients, an accurate TRV-signal was available on the post-operative echocardiogram. Pre-operative PH was associated with post-operative PH (odds ratio (OR) 3.1, 95% CI: 1.5-6.7). The prevalence of post-operative PH was 28% (52/189) (mean eSPAP 39±9mmHg). During a median post-operative follow-up of 1.7 years (IQR: 0.6-2.9) 34 patients died, of which 41% (14/34) patients had post-operative PH. Post-operative PH was a significant predictor of post-operative in-hospital adverse events (OR: 2.0, 95% CI: 1.1-4.0) and all-cause mortality (hazard ratio: 2.1, 95% CI: 1.1-4.1).
Conclusions
Persistent post-operative PH is highly prevalent in patients with severe primary MR that underwent successful elective mitral valve surgery. Pre-operative PH is an important predictor of post-operative PH. Persistent PH after surgery is associated with post-operative in-hospital adverse events and all-cause mortality.