the bluhm cardiovascular institute northwestern memorial hospital a contemporary analysis of...

The Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

A Contemporary Analysis of Pulmonary Hypertension in Patients Undergoing Mitral

Valve Surgery: Is this a Risk Factor?



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 HypertensionPulmonary Hypertension

1. Pulmonary hypertension (pHTN) is elevated arterial pressures in the pulmonary circulation, specifically systolic pulmonary arterial pressure (PASP) greater than 35 mm Hg.

2. Severe pulmonary hypertension has been identified in the Euroscore data as a factor for 30 day mortality1.

3. However, contemporary surgery may reduce that risk.

1. Pulmonary hypertension (pHTN) is elevated arterial pressures in the pulmonary circulation, specifically systolic pulmonary arterial pressure (PASP) greater than 35 mm Hg.

2. Severe pulmonary hypertension has been identified in the Euroscore data as a factor for 30 day mortality1.

3. However, contemporary surgery may reduce that 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

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

• 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.



N= 3342, Multivariate analysis 92.4% Isolated CABG or AVR 6.3% MV surgery, not reported separatelyJ Thorac Cardiovasc Surg, 2013. 146(3): p. 631-7.



N=873Mitral regurgitationMultivariate analysis

J Thorac Cardiovasc Surg, 2011. 142(6): p. 1439-52.



HypothesesHypotheses

1. Pulmonary HTN itself does not increase perioperative or long-term mortality in MV surgery patients.

2. Addition of TV surgery does not increase mortality.





Northwestern pHTN DataNorthwestern pHTN Data

• Mitral Valve surgery 2004-2014• Exclusion: TAVR, VADS, Transplants, Trauma, CARD

refusal, Endocarditis

• Mitral Valve surgery 2004-2014• Exclusion: TAVR, VADS, Transplants, Trauma, CARD

refusal, Endocarditis1571 patients)

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 GroupsUnmatched 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) 60.0 (53.0, 65.0)

<.001

NYHA Class III IV, No. (%) 112 (23%) 233 (39%) 236 (56%) 32 (67%) <.001

CABG, No. (%) 118 (24%) 178 (30%) 139 (33%) 16 (33%) 0.021

Tricuspid Valve Surgery, No. (%)

42 (8%) 138 (23%) 189 (44%) 23 (47%) <.001



Unmatched pHTNUnmatched pHTN30d Mortality: 4% vs. 1% (p<0.01)

p<0.0001



Unmatched pHTNUnmatched pHTN30d Mortality: 12%, 4%, 3%, 1% (p<0.001)

p<0.0001



Propensity Matched pHTN AnalysisPropensity Matched pHTN Analysis

• PS-Matched on: • PS-Matched on: - Age - BSA - Creatinine - Ambler score- Gender - CAD- prior MI- DM

- HL- HTN- COPD- CVA- Prior CABG- Prior valve surg- A-fib history- NYHA III/IV

- Elective- MV fnc class - TV Surgery



PS-matched Operative DataPS-matched Operative Data

VariableNo 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 (10%) 0.91

Pulmonic Valve Surgery, No. (%) 0 (0%) 1 (0%) 0.32

Mitral Valve Repair, No. (%) 347 (83%) 345 (82%) 0.86



PS-matched Operative DataPS-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%) 39 (9%) 1.00

. Type IIIb 34 (8%) 41 (10%) 0.40



PS-matched Postoperative DataPS-matched Postoperative Data

VariableNo 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) 6.0 (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 (2%) 0.79

30-Day Mortality, No. (%) 6 (1%) 9 (2%) 0.43

Ambler Score (%) 6.0 ± 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



Propensity Matched pHTN AnalysisPropensity Matched pHTN Analysis30d Mortality: 2% vs. 1% (NS, p=0.43)

p=0.39



PS-Matched by SeverityPS-Matched by Severity

Severe(PASP 50-79 mmHg)

p=0.45



PS-Matched by SeverityPS-Matched by Severity

Extreme(PASP > 80mmHg)

p=0.022



Post-surgical pHTNPost-surgical pHTN

p<0.0001 p=0.7 p<0.0001 p<0.0001



HypothesesHypotheses







TV Surgery in pHTN, UnmatchedTV Surgery in pHTN, Unmatched30d Mortality: 5% vs. 3% (NS, p=0.06)

p<0.0001



TV Surgery in pHTN, Propensity MatchedTV Surgery in pHTN, Propensity Matched30d Mortality; 5% vs. 4% (NS, p=0.8)

p=0.97



LimitationsLimitations

• Right heart catheterizations as primary source, echocardiogram as second choice

• Retrospective series• Single institution

• Right heart catheterizations as primary source, echocardiogram as second choice

• Retrospective series• Single institution



ConclusionsConclusions

• 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.

• 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.

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