Acquired cardiovascular disease
Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic valve stenosis

Read at the 90th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, May 1–5, 2010.
https://doi.org/10.1016/j.jtcvs.2011.02.028Get rights and content
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Objective

The presence of pulmonary hypertension historically has been considered a significant risk factor affecting early and late outcomes after valve replacement. Given the number of recent advances in the management of pulmonary hypertension after cardiac surgery, a better understanding of its impact on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine whether pulmonary hypertension remains a risk factor in the modern era for adverse outcomes after aortic valve replacement for aortic valve stenosis.

Methods

From January 1996 to June 2009, a total of 1080 patients underwent aortic valve replacement for primary aortic valve stenosis, of whom 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had pulmonary hypertension. Pulmonary hypertension was defined as mild (sPAP 35–44 mm Hg), moderate (45–59 mm Hg), or severe (≥ 60 mm Hg). In the group of patients with pulmonary hypertension, 204 had postoperative echocardiograms.

Results

Operative mortality was significantly higher in patients with pulmonary hypertension (47/506, 9%, vs 31/574, 5%, P = .02). The incidence of postoperative stroke was similar (P = .14), but patients with pulmonary hypertension had an increased median hospital length of stay (8 vs 7 days, P = .001) and an increased incidence of prolonged ventilation (26% vs 17%, P < .001). Preoperative pulmonary hypertension was an independent risk factor for decreased long-term survival (relative risk 1.7, P = .02). Those with persistent pulmonary hypertension postoperatively had decreased survival. Five-year survival (Kaplan–Meier) was 78% ± 6% with normal sPAP and 77% ± 7% with mild pulmonary hypertension postoperatively, compared with 64% ± 8% with moderate and 45% ± 12% with severe pulmonary hypertension (P < .001).

Conclusions

In patients undergoing aortic valve replacement, preoperative pulmonary hypertension increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe pulmonary hypertension after aortic valve replacement had decreased long-term survival. These data suggest that pulmonary hypertension had a significant impact on outcomes in patients undergoing aortic valve replacement and should be considered in preoperative risk assessment.

CTSNet classification

11.4
35
35.2

Abbreviations and Acronyms

AVR
aortic valve replacement
CABG
coronary artery bypass graft
LVEDP
left ventricular end-diastolic pressure
LVEF
left ventricular ejection fraction
PAP
pulmonary artery pressure
PH
pulmonary hypertension
PVR
pulmonary vascular resistance
RR
relative risk
sPAP
systemic pulmonary arterial pressure

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Disclosures: Authors have nothing to disclose with regard to commercial support.