Pulmonary Hypertension in Valvular Heart Disease Surgery: Risk and Prognosis.

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

OBJECTIVES: 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.

METHODS: 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.

RESULTS: 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.

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