Pulmonary Hypertension in Valvular Heart Disease Surgery: Risk and Prognosis

Left heart disease is the most common cause of pulmonary hypertension (PH), and when present is associated with higher surgical risk.

Analyze the effect of PH severity on morbidity, early and late mortality in patients with pulmonary artery systolic pressure (PASP) over 30mmHg that underwent valvular heart surgery.

Retrospective observational study including all patients with PH, defined as PASP>30 mmHg that underwent isolated valvular heart surgery, between 2007 and 2016. Exclusion criteria were: active endocarditis, congenital heart disease, transcatheter aortic valve implantation, reoperations and emergent surgery. The study population included 607 patients with a mean age of 69.6 years and a mean PASP of 52.5 mmHg. Mean follow-up for all-cause mortality was 4.4(0-11) years in 99.7% of patients. MACCE (Major Adverse Cardiac and Cerebrovascular event) was defined as at least one of the following: in-hospital mortality, stroke, post-operative myocardial infarction, severe arrhythmia or multiple organ failure. PASP was evaluated as a continuous variable. Simple and multivariable logistic regression was performed to evaluate the in-hospital mortality and MACCE. Cox regression was used for long term follow-up and one-sample log-rank test for comparison with age adjusted general population.

The in-hospital mortality was 3.2% and PASP was an independent predictor on univariable analysis (OR:1.06; 95%CI:1.03- 1.09; p<0.001). On multivariable logistic regression PH remains an independent predictor of in- -hospital mortality (OR:1.08; 95%CI:1.04-1.12; p<0.001) in addition to age (OR:1.08; 95%CI:1.01-1.17; p=0.044). MACCE was observed in 11.4% and PASP was an independent predictor on univariable analysis (OR:1.03; 95%CI:1.01- 1.04; p<0.001). On multivariable logistic regression PASP remains an independent predictor of MACCE (OR:1.02; 95%CI:1.01-1.04; p=0.011) as well as hemodialysis (OR:7.16; 95%CI:1.73-29.63; p=0.007). The independent predictors of long term mortality were male gender (p=0.011), older age (p<0.001), higher body mass index (p=0.013), urgent surgery (p=0.027), pulmonary disease (p=0.042) and more than one valve procedure (p=0.004 for 2 valves and p=0.006 for 3 valves). PASP was not an independent predictor of long term mortality (p=0.142). Compared with an age adjusted general population, patients with PH had a significantly lower survival rate(p<0.001), more evident 4 years after the procedure.

Higher PASP is a risk factor for in-hospital mortality and MACCE, but there was no significant impact on long term mortality.