Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: implications for timing of surgery

Objective: We investigated the impact of preoperative pulmonary hypertension (PH) on early and late outcomes after mitral valve operation for mitral regurgitation.

Methods: Systolic pulmonary artery pressure (sPAP) was measured before operation in 873 consecutive patients who underwent mitral valve surgery for mitral regurgitation between January 2002 and January 2010. PH was classified as none (sPAP < 40 mm Hg), mild (40 ≤ sPAP < 50 mm Hg), moderate (50 ≤ sPAP < 60 mm Hg), or severe (sPAP ≥ 60 mm Hg).

Results: Increased preoperative sPAP was associated with greater left ventricular dysfunction and dilation, left atrial enlargement, more atrial fibrillation, and tricuspid regurgitation. Operative mortality was correlated with the degree of preoperative PH (2%, 3%, 8%, and 12% for none, mild, moderate, and severe PH, respectively, P < .0001). Long-term survival was related to preoperative sPAP (5-year survival: 88%, 79%, 65%, and 53% for none, mild, moderate, and severe PH, respectively; P < .0001). In multivariable analyses, sPAP was a predictor of both operative mortality (odds ratio, 1.023 per 1 mm Hg increase; 95% confidence interval, 1.003-1.044; P = .0270) and late death (hazard ratio, 1.018 per 1 mm Hg increase; 95% confidence interval, 1.007-1.028; P = .001). Among 284 patients with isolated degenerative mitral regurgitation due to leaflet prolapse, actuarial survival was 97.5%, 91.2%, and 80.5% for none, mild, and moderate to severe PH, respectively (P = .0002).

Conclusions: Preoperative sPAP is a powerful predictor of early and late survival after mitral valve operation for mitral regurgitation. Even modest increases in sPAP adversely affect outcomes. Mitral valve operation should be performed before the development of PH.