Persistent pulmonary hypertension after mitral valve surgery: does surgical procedure affect outcome?

Abstract

Background and aim of the study: Recently published data suggest that prosthesis-patient mismatch is common after mitral valve replacement (MVR), and manifests as persistent pulmonary hypertension. The study aim was to determine the prevalence and severity of pulmonary hypertension after mitral valve surgery, including mitral valve repair, and to determine whether surgery type affects the prevalence of post-operative pulmonary hypertension.

Methods: Matched preoperative and > or =1 year postoperative Doppler estimates of right ventricular systolic pressure (RVSP) were evaluated in a cohort of 179 patients who underwent MVR or repair (33 after bioprosthetic valve replacement, 20 after mechanical valve replacement, 43 after physiological valve repair (predominantly for myxomatous disease), 78 after undersized annuloplasty for functional regurgitation, and five after repair of rheumatic stenosis).

Results: Patients undergoing repair of function mitral regurgitation had a lower left ventricular ejection fraction. The postoperative mean transmitral gradient was slightly higher for patients after bioprosthetic valve replacement (6.9 +/- 2.6 mmHg) compared to mechanical valve replacement (5.2 +/- 2.8 mmHg; p = 0.03), physiological repair (5.2 +/- 2.8 mmHg; p = 0.05), or repair of functional regurgitation (5.5 +/- 2.8 mmHg; p = 0.02). Pulmonary hypertension was common (present in 78% of patients before and 64% after surgery), and there were no significant differences between groups in the prevalence of postoperative pulmonary hypertension. The RVSP tended to decrease in all groups, but reached statistical significance only for patients undergoing bioprosthetic replacement (-9 +/- 24 mmHg; p = 0.04), mechanical replacement (-10 +/- 14 mmHg; p = 0.003) or physiological repair (-6 +/- 16 mmHg; p = 0.01).

Conclusion: Pulmonary hypertension is common before and after mitral valve surgery. Although there were at least trends toward lower pulmonary artery pressures regardless of surgery type, significant decreases were noted only after MVR and physiological repair. A slightly higher postoperative mean transmitral gradient after bioprosthetic valve replacement may have contributed to postoperative pulmonary hypertension. The physiological repair of organic, non-rheumatic mitral regurgitation appears to offer favorable hemodynamics and a relatively low rate of postoperative pulmonary hypertension.