A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel.

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Presentation transcript:

A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel for the opportunity to present our work. Daniel H. Enter M.D., Anthony Zaki B.S., Brett Duncan M.D., Jane Kruse R.N. B.S.N., Andrei Adin-Cristian Ph.D., Zhi Li, M.S., S. Chris Malaisrie M.D., James D. Thomas M.D., Patrick McCarthy M.D.

Pulmonary Hypertension Pulmonary hypertension (pHTN) is elevated arterial pressures in the pulmonary circulation, specifically systolic pulmonary arterial pressure (PASP) greater than 35 mm Hg. Severe pulmonary hypertension has been identified in the Euroscore data as a factor for 30 day mortality1. However, contemporary surgery may reduce that risk. pHTN has long been considered a risk factor in cardiac sugery – identified as such in the Euroscore database. However, contemporary surgical techniques may reduce this risk. 1Group, E.S. EuroSCORE II Calculator. European System for Cardiac Operative Risk Evaluation, http://www.euroscore.org/calc.html.

2014 AHA/ACC Guidelines for the Management of Patients With Valvular Heart Disease Severe pHTN (PASP >50 mm Hg) is considered a class IIa indication for surgery in chronic severe MR1 Level of Evidence B 1Nishimura, R.A., et al. J Thorac Cardiovasc Surg, 2014. 148(1): p. e1-e132. MV repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (PA systolic arterial pressure >50 mm Hg)

N= 3342, Multivariate analysis 92.4% Isolated CABG or AVR Recent studies have demonstrated operative risk associated with elevated pulmonary pressures, and implied this should be taken into account in the STS score. N= 3342, Multivariate analysis 92.4% Isolated CABG or AVR 6.3% MV surgery, not reported separately J Thorac Cardiovasc Surg, 2013. 146(3): p. 631-7.

Multivariate analysis In mitral valve surgery, we have seen that higher pressure is associated with long-term mortality. N=873 Mitral regurgitation Multivariate analysis J Thorac Cardiovasc Surg, 2011. 142(6): p. 1439-52.

Hypotheses Pulmonary HTN itself does not increase perioperative or long-term mortality in MV surgery patients. Addition of TV surgery does not increase mortality.

Northwestern pHTN Data Mitral Valve surgery 2004-2014 Exclusion: TAVR, VADS, Transplants, Trauma, CARD refusal, Endocarditis 1571 patients) We analysed over 1500 patients underwent surgery between 2004-2014, 29% did not have pulmonary hypertension, defined as pulmonary systolic pressure < 35mmHg, 35% had moderat pHTN with pressures of 33-49, 25% had severe pHTN with pressures 50-79, and 3% had Extreme pulmonary HTN with pressures greater than 80. No PHTN (PASP < 35 mmHg) 496 (29%) Moderate (PASP 35-49 mmHg) 600 (35%) Severe (PASP 50-79 mmHg) 426 (25%) Extreme (PASP > 80 mmHg) 49 (3%) 143 (8%) unknown

Unmatched Groups Variable No (<35mmHg) (N=496) Moderate (35- 49mmHg) (N=600) Severe (50-79mmHg) (N=426) Extreme (>=80mmHg) (N=49) P-value Age 59.4 ± 13.9 65.0 ± 12.9 68.0 ± 12.1 65.7 ± 13.1 <.001 Gender (female), No. (%) 202 (41%) 279 (47%) 213 (50%) 29 (59%) 0.008 Ejection Fraction, Median (Q1, Q3) 60.0 (53.0, 65.0) 57.0 (45.0, 61.5) 55.0 (43.0, 63.0) NYHA Class III IV, No. (%) 112 (23%) 233 (39%) 236 (56%) 32 (67%) CABG, No. (%) 118 (24%) 178 (30%) 139 (33%) 16 0.021 Tricuspid Valve Surgery, No. (%) 42 (8%) 138 189 (44%) 23 Patients with pulmonary hypertension were older, more likely to be female, and had higher NYHA class, and were more likely to have concominant tricuspid valve surgery.

Unmatched pHTN 30d Mortality: 4% vs. 1% (p<0.01) p<0.0001 In our unmatched group, pulmonary hypertension had a higher 30d mortality, 4% versus 1%, and higher 5 year mortality at 81% compared to nearly 93%.

Unmatched pHTN 30d Mortality: 12%, 4%, 3%, 1% (p<0.001) p<0.0001 Stratifying by degree of pulmonary hypertension,

Propensity Matched pHTN Analysis PS-Matched on: Age HL Elective BSA HTN MV fnc class Creatinine COPD TV Surgery Ambler score CVA Gender Prior CABG CAD Prior valve surg prior MI A-fib history DM NYHA III/IV After propensity matching these patients,

PS-matched Operative Data Variable No PHTN (N=420) PHTN (N=420) P-value Clamp Time (min), Median (Q1, Q3) 81.0 (66.0, 110.0) 90.0 (67.0, 118.0) 0.09 CABG, No. (%) 115 (27%) 120 (29%) 0.70 Aortic Valve Surgery, No. (%) 66 (16%) 73 (17%) 0.52 Tricuspid Valve Surgery, No. (%) 41 (10%) 42 0.91 Pulmonic Valve Surgery, No. (%) (0%) 1 0.32 Mitral Valve Repair, No. (%) 347 (83%) 345 (82%) 0.86 After propensity matching, we can see that concominant surgery, and repair versus replacement were equivalent.

PS-matched Operative Data Carpentier’s Classification of Mitral Regurgitation No PHTN (N=420) PHTN (N=420) P- value . Type I 46 (11%) 42 (10%) 0.65 . Type II 254 (60%) 262 (62%) 0.57 . Type IIIa 39 (9%) 1.00 . Type IIIb 34 (8%) 41 0.40 The type of mitral regurgitation was also similar between patients with and without pulmonary hypertension.

PS-matched Postoperative Data Variable No PHTN (N=420) PHTN (N=420) P- value Total ICU Hours, Median (Q1, Q3) 31.3 (24.3, 60.0) 31.4 (24.1, 68.8) 0.62 Total Length of Stay (Days), Median (Q1, Q3) 6.0 (5.0, 8.0) (5.0, 9.0) 0.32 Discharged to Home, No. (%) 355 (86%) 351 (84%) 0.64 Readmission within 30 Days, No. (%) 45 (11%) 50 (12%) 0.59 Operative Mortality, No. (%) 7 (2%) 8 0.79 30-Day Mortality, No. (%) 6 (1%) 9 0.43 Ambler Score (%) ± 7.8 6.4 ± 7.3 0.46 STS Risk Score (%), Median (Q1, Q3) 0.6 (0.3, 1.7) 0.9 (0.4, 2.1) 0.11 All-Cause Long-Term Mortality, No. (%) 28 (7%) 38 (9%) 0.20 After matching, we did not note a difference in 30-day mortality, 5-year mortality, or length of stay.

Propensity Matched pHTN Analysis 30d Mortality: 2% vs. 1% (NS, p=0.43) p=0.39

PS-Matched by Severity Severe (PASP 50-79 mmHg) p=0.45

PS-Matched by Severity Extreme (PASP > 80mmHg) p=0.022

Post-surgical pHTN p=0.7 p<0.0001 p<0.0001 p<0.0001

Hypotheses Pulmonary HTN itself does not increase perioperative or long-term mortality in MV surgery patients. Addition of TV surgery does not increase mortality.

TV Surgery in pHTN, Unmatched 30d Mortality: 5% vs. 3% (NS, p=0.06) p<0.0001

TV Surgery in pHTN, Propensity Matched 30d Mortality; 5% vs. 4% (NS, p=0.8) p=0.97

Limitations Right heart catheterizations as primary source, echocardiogram as second choice Retrospective series Single institution

Conclusions Severe pulmonary hypertension is not an independent risk factor for short or long-term mortality in patients undergoing mitral valve surgery. Tricuspid valve surgery does not increase mortality in patients with pulmonary hypertension undergoing mitral valve surgery. Pulmonary hypertension itself is not a reason to deny patients mitral valve surgery.

A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery: Is this a Risk Factor? Thank you to the society and panel for the opportunity to present our work. Daniel H. Enter M.D., Anthony Zaki B.S., Brett Duncan M.D., Jane Kruse R.N. B.S.N., Andrei Adin-Cristian Ph.D., Zhi Li, M.S., S. Chris Malaisrie M.D., James D. Thomas M.D., Patrick McCarthy M.D.