High-risk mitral valve replacement in severe pulmonary hypertension—30 years experience1

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Abstract

Objective:

In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP)>50 mmHg; pulmonary vascular resistance (PVR), 690±46 dyn/s per m2). We reviewed our early and late results in this high-risk subgroup.

Methods:

We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4±0.2 years per patient. The overall early mortality rate was 10.5% (n=40) and stayed at about the same level over the years, although patients characteristics have changed to much older patients and more reoperations. To clarify this fact we divided our data in results according to the decades in which the operations were carried out. The clinical preoperative status and results were as follows (* P<0.05; ** P<0.01 compared with previous decade). In the decades between 1963 and 1973 (I), 1974 and 1983 (II) and 1984 and 1993 (III) we operated on n=95 (I), n=185 (II), and n=102 (III) patients with a mean age of 43±1 (I), 50±1** (II), and 58±1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6%** (III). The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (III); late mortalities lowered from 5.77 (I), over 4.95 (II), and up to 3.39%** (III) patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0±0.1 (I), 3.2±0.1 (II) and 3.3±0.1 (III) to 2.4±0.2 (I), 2.4±0.1 (II) and 2.3±0.1 (III) postoperatively.

Results:

Compared with routine elective MVR with a mortality rate of 3.6% (P<0.01), early mortality is high. But once the patient survives the perioperative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as well are not significantly different. In spite of on average 15 years older multimorbid patients with therefore higher complication rates, early results improved slightly, which could be explained by better operative techniques, perioperative treatment and nursing (online monitoring with immediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes.

Conclusion:

According to our results, we recommend MVR in severe pulmonary hypertension even in the elderly, with a high but acceptable risk and good long-term results.

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