Preoperative Pulmonary Hypertension Is Associated with Postoperative Left Ventricular Dysfunction in Chronic Organic Mitral Regurgitation: An Echocardiographic and Hemodynamic Study

doi:10.1016/j.echo.2006.03.016

Journal of the American Society of Echocardiography

Volume 19, Issue 8, August 2006, Pages 1051-1055

https://doi.org/10.1016/j.echo.2006.03.016 Get rights and content

Background

Some degree of pulmonary hypertension (PHTN) is common in patients with chronic mitral regurgitation. The aim of this study was to determine whether preoperative PHTN is associated with postoperative left ventricular (LV) dysfunction.

Methods

The study included 79 patients with chronic organic mitral regurgitation. Preoperative and postoperative LV function was assessed by echocardiography. Preoperative and postoperative hemodynamics were evaluated by a pulmonary artery catheter.

Results

Pulmonary artery systolic pressure decreased postoperatively (pre 49 ± 14 vs. post 36 ± 11 mm Hg, P < .01). Postoperative LV ejection fraction was significantly reduced in patients with preoperative PHTN (pre 61 ± 11% vs post 49 ± 12%, P < .01). A stepwise multivariate regression analysis showed that preoperative pulmonary artery systolic pressure and LV end-systolic dimension were independent predictors of postoperative LV ejection fraction (r = −0.53, P < .001, and r = −0.34, P < .05, respectively).

Conclusion

Preoperative PHTN is associated with postoperative LV dysfunction in patients with chronic organic mitral regurgitation undergoing mitral valve operation.

Section snippets

Patient Population

The study included 79 patients with chronic organic MR who had complete echocardiographic and hemodynamic studies using right and left cardiac catheterization before mitral valve operation from 1994 to 2002 at our institution. All patients underwent mitral valvular operation (repair or replacement). During the same period, there were a total of 164 patients who underwent mitral valve operation for severe organic MR. All the patients enrolled into our study had chronic organic MR defined as a

Preoperative Data

Table 1 lists preoperative cardiac catheterization data. Using catheter-measured pressure as the standard, 64 patients had preoperative PHTN (PAPs > 30 mm Hg) and 15 patients had normal PAPs (≤30 mm Hg). The patients were further divided into 3 groups according to PAPs (group I, normal PAPs ≤ 30 mm Hg; group II, mild PHTN with PAPs 31-49 mm Hg; group III, moderate or severe PHTN with PAPs ≥ 50 mm Hg). Table 2 lists preoperative echocardiographic data and the NYHA functional class in the 3

Discussion

Prevalence of heart valvular disease has increased in recent decades. The Framingham study noted that the prevalence of MR increased 1.3-fold with each decade of life.⁹ It is anticipated that the prevalence of MR will increase even further because of the rapidly growing aged population in the United States and worldwide.

Optimal timing of surgical intervention of chronic MR is evolving. Previous studies showed that postoperative LV systolic dysfunction is associated with unfavorable surgical

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Cited by (28)

The Right Heart-Pulmonary Circulation Unit and Left Heart Valve Disease
2018, Heart Failure Clinics
Citation Excerpt :
Nevertheless, management of patients with secondary MR is still challenging in case of severe asymptomatic MR.2,17 The prevalence of PH in mitral stenosis (MS) is related to MS severity and clinical status and varies ranging from 14% to 33% for moderate PH and 5% to 9.6% for severe PH.29,30 PH is closely associated with heart failure symptoms and recent studies confirmed the prognostic value of PH in MS.2,31 Yang and colleagues32 suggested that moderate and severe PH was associated with adverse outcomes in MS after adjustment of confounding factors. Similarly, Fawzy and colleagues33 determined that severe PH (sPAP >60 mm Hg) was associated with higher risk of cardiovascular events at midterm follow-up after percutaneous balloon.
Pulmonary Hypertension in Aortic Stenosis and Mitral Regurgitation: Rest and Exercise Echocardiography Significance
2016, Progress in Cardiovascular Diseases
Citation Excerpt :
In asymptomatic primary MR, the concomitant presence of significant MR and PH is relatively rare. In this group, PH accounts for approximately 6–30% but increases to 58% during exercise.3,24,26,46,47 Previous studies have shown that the presence of PH in patients undergoing MV surgery is associated with a poor outcome in terms of survival, LV dysfunction, limited LV reverse remodeling, symptoms improvement, and persistence of post-operative PH.44–48 The presence of PH doubles the risk of postoperative death or occurrence of heart failure.43
Valvular heart disease is a common cause of increased mean pulmonary artery pressure (PAP). Aortic stenosis and mitral regurgitation are frequently accompanied by pulmonary hypertension (PH), especially when they are severe and symptomatic. In asymptomatic patients, PH is rare, though the exact prevalence is unknown and mainly stems from the severity of the valvular heart disease and the presence of diastolic dysfunction. Exercise echocardiography has recently gained interest in depicting PH. In these asymptomatic patients, exercise PH is observed in about >40%. Either PH at rest (systolic PAP >50 mmHg) or during exercise (systolic PAP >60 mmHg) is a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology.
Effect of Pulmonary Vascular Pressures on Long-Term Outcome in Patients With Primary Mitral Regurgitation
2016, Journal of the American College of Cardiology
Citation Excerpt :
However, most of these studies had a small sample size with heterogeneous endpoints (development of post-operative LV dysfunction, death, and/or development of heart failure) with relatively short-term follow-up. Early studies demonstrated that PH was associated with post-operative LV dysfunction (26) and with increased operative and long-term mortality in patients undergoing MV replacement (24,25). In a study by Le Tourneau et al. (27) of 256 patients with primary MR, RVSP >50 mm Hg was an independent predictor of mortality after MV surgery.
Primary mitral regurgitation (MR) is a growing health problem due to the aging population.
The purpose of this study was to assess the impact of baseline pulmonary hypertension on long-term outcomes in patients with significant primary MR and preserved left ventricular ejection fraction (LVEF).
We studied 1,318 patients with ≥3+ primary MR and LVEF ≥60% using echocardiography at rest; they were evaluated at our center from 2005 to 2008. Baseline clinical and echocardiography data were recorded, and the Society of Thoracic Surgeons (STS) score was calculated. The primary outcome was death.
Mean STS score was 3.98 ± 1%; 54% of patients were in New York Heart Association (NYHA) functional class I and 31% were in NYHA functional class II; and 18% had atrial fibrillation (AF). Mean LVEF, mitral effective regurgitant orifice, indexed LV end-systolic diameter (LVESD), and right ventricular systolic pressure (RVSP) were 62 ± 2%, 0.56 ± 0.30 cm², 1.6 ± 0.3 cm/m², and 37 ± 14 mm Hg, respectively. At 7.1 ± 2.0 years, 86% had mitral valve (MV) surgery. Death occurred in 130 (10%) patients. On Cox multivariable analysis, baseline RVSP, together with age, baseline NYHA functional class, pre-operative AF, coronary artery disease, and indexed LVESD were associated with a higher rate of longer term mortality (all p < 0.01), whereas MV surgery (as a time-dependent covariate) was associated with improved survival (p < 0.001). Addition of RVSP to the STS score significantly reclassified the risk for longer term mortality (integrated discrimination index: 0.07; p < 0.001); 77% patients who died had RVSP ≥35 mm Hg.
In patients with significant primary MR and preserved LVEF, baseline RVSP is independently associated with long-term survival. Impact of RVSP is progressive and not confined to those with the highest baseline values.
Pulmonary Pressures and Outcome in Primary Mitral Regurgitation: Paradigm Shift From Rung to Ladder<sup>∗</sup>
2016, Journal of the American College of Cardiology
Pulmonary hypertension in valvular disease: A comprehensive review on pathophysiology to therapy from the HAVEC group
2015, JACC: Cardiovascular Imaging
Pulmonary hypertension (PH) is a classic pathophysiological consequence of left-sided valvular heart disease (VHD). However, as opposed to other forms of PH, there are relatively few published data on the prevalence, impact on outcome, and management of PH with VHD. The objective of this paper is to present a systematic review of PH in patients with VHD. PH is found in 15% to 60% of patients with VHD and is more frequent among symptomatic patients. PH is associated with higher risk of cardiac events under conservative management, during valve replacement or repair procedures, and even following successful corrective procedures. In addition to its usefulness in assessing the presence and severity of VHD, Doppler echocardiography is a key tool in diagnosis of PH and assessment of its repercussion on right ventricular function. Assessment of pulmonary arterial pressure during exercise stress echocardiography may provide additional prognostic information beyond resting evaluation. Cardiac magnetic resonance is also useful for assessing right ventricular geometry and function, which provide additional prognostic information in patients with VHD and PH.
Association of heart rhythm with exercise capacity after operation for chronic mitral regurgitation
2012, Annals of Thoracic Surgery
Although atrial fibrillation (AF) and decreased exercise capacity are common in chronic mitral regurgitation patients, the relationship between rhythm status and exercise capacity after corrective surgery is largely unknown.
Seventy-one patients undergoing repair or replacement of mitral valve for chronic severe mitral regurgitation were examined with preoperative and 6 months' postoperative cardiopulmonary exercise test and two-dimensional echocardiography. Patients were divided into three groups according to preoperative versus postoperative rhythm (sinus/sinus, SS [n = 42]; AF/sinus, AS [n = 17]; AF/AF, AA group [n = 12]).
Preoperative maximal oxygen consumption was lower and ventilatory efficiency was higher in the AS and AA groups compared with the SS group. However, maximal oxygen consumption improved only in the AS group at 6 months' postoperative cardiopulmonary exercise test (24.0 ± 6.9 versus 24.6 ± 6.1 mL · kg⁻¹ · min⁻¹ in the SS group, 19.3 ± 5.9 versus 23.2 ± 6.4 mL · kg⁻¹ · min⁻¹ in the AS group, 19.8 ± 5.4 versus 18.8 ± 5.1 mL · kg⁻¹ · min⁻¹ in the AA group; p = 0.016 for maximal oxygen consumption by analysis of covariance) as well as ventilatory efficiency. Echocardiography verified more significant reduction of left atrial volume in the SS and AS groups than in the AA group (172.2 ± 68.0 versus 96.7 ± 31.0 mL in the SS group, 247.5 ± 77.8 versus 129.2 ± 25.7 mL in the AS group, 316.7 ± 210.0 versus 192.0 ± 95.0 mL in the AA group; p = 0.001 for left atrial volume by analysis of covariance) as well as pulmonary artery systolic pressure. When analyzed for significant predictors of postoperative maximal oxygen consumption, being in the AS group but not the SS group was a significant positive predictor when compared with the AA group (β = 5.475; p = 0.006).
Successful sinus conversion of AF, preferably by maze operation, in patients undergoing surgical correction of chronic severe mitral regurgitation confers improved exercise capacity. Reduction of left atrial volume and pulmonary artery pressure may contribute to this improvement.

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: Supported in part by a grant-in-aid from the American Society of Echocardiography, a Scientists Development Grant from the American Heart Association, and the General Clinic Research Center (National Institutes of Health) (Dr Pu).

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Original articlePreoperative Pulmonary Hypertension Is Associated with Postoperative Left Ventricular Dysfunction in Chronic Organic Mitral Regurgitation: An Echocardiographic and Hemodynamic Study

Background

Methods

Results

Conclusion

Section snippets

Patient Population

Preoperative Data

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Valvular heart disease

N Engl J Med

Original article
Preoperative Pulmonary Hypertension Is Associated with Postoperative Left Ventricular Dysfunction in Chronic Organic Mitral Regurgitation: An Echocardiographic and Hemodynamic Study