Tissue Valves in Patients <65 years old: A Viable Alternative to

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.

Northwestern Memorial Hospital

The Bluhm Cardiovascular Institute

Pulmonary 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 mortality 1 .

3.

However, contemporary surgery may reduce that risk.

1 Group, 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 MR 1

•

Level of Evidence B

1 Nishimura, R.A., et al. J Thorac Cardiovasc Surg, 2014. 148 (1): p. e1-e132.



N= 3342, Multivariate analysis

92.4% Isolated CABG or AVR

J Thorac Cardiovasc Surg, 2013. 146 (3): p. 631-7.

6.3% MV surgery, not reported separately



N=873

Mitral regurgitation

Multivariate analysis

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



Hypotheses

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 Data

•

Mitral Valve surgery 2004-2014

•

Exclusion: TAVR, VADS, Transplants, Trauma, CARD refusal, Endocarditis

1571 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 Groups

Variable

No

(<35mmHg)

(N=496)

Moderate (35-

49mmHg)

(N=600)

59.4

±

13.9 65.0

±

12.9 Age

Gender (female), No. (%) 202 (41%) 279 (47%)

Ejection Fraction, Median

(Q1, Q3)

60.0 (53.0,

65.0)

NYHA Class III IV, No. (%) 112 (23%)

CABG, No. (%)

Tricuspid Valve Surgery,

No. (%)

118 (24%)

42 (8%)

57.0 (45.0,

61.5)

233 (39%)

178 (30%)

138 (23%)

Severe

(50-79mmHg)

(N=426)

68.0

±

12.1

213 (50%)

55.0 (43.0, 63.0)

236 (56%)

139 (33%)

189 (44%)

Extreme

(>=80mmHg)

(N=49)

P-value

65.7

±

13.1 <.001

29 (59%) 0.008

60.0 (53.0,

65.0)

<.001

32 (67%) <.001

16 (33%) 0.021

23 (47%) <.001



Unmatched pHTN

30d Mortality: 4% vs. 1% (p<0.01) p<0.0001

Group Year1 Year2 Year3 Year4 Year5

No

Yes

97.1%

90.2%

95.5%

87.8%

94.3%

85.6%

93.2%

83.8%

92.8%

81.3%

FU

4.0±2.8

4.1±2.8



Unmatched pHTN

30d Mortality: 12% , 4% , 3% , 1% (p<0.001) p<0.0001

No

Group Year1 Year2 Year3 Year4 Year5 FU

97.1% 95.5% 94.3% 93.2% 92.8% 4.0±2.8

Moderate 93.5% 91.8% 89.5% 88.1% 86.7% 4.4±2.7

Severe 87.1% 83.8% 81.5% 78.9% 74.5% 3.7±2.7

Extreme 74.9% 72.7% 72.7% 72.7% 72.7% 3.5±3.0



Propensity Matched pHTN Analysis

•

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 Data

Variable

Clamp Time (min), Median (Q1, Q3)

CABG, No. (%)

Aortic Valve Surgery, No. (%)

Tricuspid Valve Surgery, No. (%)

Pulmonic Valve Surgery, No. (%)

Mitral Valve Repair, No. (%)

No PHTN

(N=420)

81.0 (66.0, 110.0)

115 (27%)

66 (16%)

41 (10%)

0 (0%)

347 (83%)

PHTN

(N=420)

P-value

90.0 (67.0, 118.0) 0.09

120 (29%)

73 (17%)

42 (10%)

1 (0%)

345 (82%)

0.70

0.52

0.91

0.32

0.86



PS-matched Operative Data

Carpentier’s Classification of

Mitral Regurgitation

. Type I

. Type II

. Type IIIa

. Type IIIb

No PHTN

(N=420)

46 (11%)

254 (60%)

39 (9%)

34 (8%)

PHTN

(N=420)

42 (10%)

262 (62%)

39 (9%)

41 (10%)

Pvalue

0.65

0.57

1.00

0.40



PS-matched Postoperative Data

Variable

Total ICU Hours, Median (Q1, Q3)

Total Length of Stay (Days), Median

(Q1, Q3)

Discharged to Home, No. (%)

Readmission within 30 Days, No. (%)

Operative Mortality, No. (%)

30-Day Mortality, No. (%)

Ambler Score (%)

STS Risk Score (%), Median (Q1, Q3)

All-Cause Long-Term Mortality, No. (%)

No PHTN

(N=420)

31.3 (24.3, 60.0)

6.0 (5.0, 8.0)

355 (86%)

45 (11%)

7 (2%)

6 (1%)

6.0

±

7.8

0.6 (0.3, 1.7)

28 (7%)

PHTN

(N=420)

Pvalue

31.4 (24.1, 68.8) 0.62

6.0 (5.0, 9.0) 0.32

351 (84%)

50 (12%)

8 (2%)

9 (2%)

6.4

±

7.3

0.9 (0.4, 2.1)

38 (9%)

0.64

0.59

0.79

0.43

0.46

0.11

0.20



Propensity Matched pHTN Analysis

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

Group Year1 Year2 Year3 Year4 Year5

No 96.5% 95.1% 93.6% 92.7%

FU

92.2% 4.0±2.8

Yes 95.2% 94.6% 92.7% 91.3% 88.9% 4.6±2.7



p=0.45

PS-Matched by Severity

Severe

(PASP 50-79 mmHg)



p=0.022

PS-Matched by Severity

Extreme

(PASP > 80mmHg)



Post-surgical pHTN p=0.7

p<0.0001

p<0.0001

p<0.0001



Hypotheses

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.



TV Surgery in pHTN, Unmatched

30d Mortality: 5% vs. 3% (NS, p=0.06) p<0.0001

Group

PulHTN, No TV

PulHTN, TV

Year1 Year2 Year3 Year4 Year5 FU

93.5% 91.3% 88.9% 87.3% 85.5% 4.2±2.7

83.0% 78.7% 72.7% 76.6% 72.7% 3.7±2.8



TV Surgery in pHTN, Propensity Matched

30d Mortality; 5% vs. 4% (NS, p=0.8) p=0.97

Group

PulHTN, No TV

PulHTN, TV

Year1 Year2 Year3 Year4 Year5 FU

89.3% 83.7% 80.8% 78.3% 77.3% 3.7±2.7

84.7% 82.2% 81.5% 79.8% 77.1% 3.8±2.9



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?

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.



Tissue Valves in Patients <65 years old: A Viable Alternative to

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