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Purpose: Pulmonary hypertension (PH) is a frequent finding in patients with severe mitral regurgitation (MR). The PH can be due to increased pulmonary venous pressure, increased pulmonary vascular resistance (PVR) or both. A new echocardiography method identifies patients with increased PVR by assessing pressure reflection (PR) in the pulmonary circulation. We hypothesized that the presence of PR negatively affects the postoperative mortality and morbidity.Methods: The study population consisted of 107 patients. We selected three variables related to PR: the interval from valve opening to peak velocity in the pulmonary artery, the interval between pulmonary artery peak velocity and peak tricuspid velocity and the right ventricular pressure increase after peak velocity in the pulmonary artery. The patients were divided into two groups: Group 1 without PR and Group 2 with at least one PR variable. Days with ≥ 2 vasoactive drugs, hours with ventilatory support and hours in the intensive care unit (ICU) were used to describe morbidity.Results: The mean age ± SD was 65±15 years and 73% were males. Sixty patients (56%) had PA systolic pressure>40 mmHg and 19 (18%) had severe PH with pressure>60 mmHg. The Figure shows box plots comparing Group 1 (n=58) and Group 2 (n=49). The in-hospital mortality was 10% in Group 2 and 0% in Group 1 (p=0.03). The proportion with >24 hours at the ICU was 67% in Group 2 versus 24% (p<0.0001) in Group 1, >17 hours with ventilatory support was 36% versus 10% (p=0.003) and ≥2 vasoactive drugs was 48% versus 20% (p=0.004).Conclusion: PR in the pulmonary circulation identifies patients with increased postoperative mortality and morbidity. By considering both PR and severe PH more mitral surgery patients at risk are identified.