1. 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.

2. 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,

3. 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, (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)

4. 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, (3): p

5. 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, (6): p

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

7. Northwestern pHTN Data
Mitral Valve surgery
Exclusion: TAVR, VADS, Transplants, Trauma, CARD refusal, Endocarditis
1571 patients)
We analysed over 1500 patients underwent surgery between , 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 mmHg)
600 (35%)
Severe
(PASP mmHg)
426 (25%)
Extreme
(PASP > 80 mmHg)
49 (3%)
143 (8%) unknown

8. Unmatched Groups Variable No (<35mmHg) (N=496)
Moderate ( mmHg) (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, )
57.0
(45.0, )
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.

9. 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%.

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

11. 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,

12. 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.

13. 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.

14. 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.

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

16. PS-Matched by Severity
Severe
(PASP mmHg)
 p=0.45

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

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

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

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

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

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

23. 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.

24. 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.