Outcomes of Repeat Mitral Valve Surgery in Patients with Pulmonary Hypertension

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> We sought to study the outcomes of redo-mitral valve surgery in patients with pulmonary hypertension. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> We reviewed data on redo mitral valve surgery in patients with pulmonary hypertension measured by Swan-Ganz catheter (mean pulmonary artery pressure ≥ 25 mm Hg or systolic pulmonary artery pressure ≥ 40 mm Hg). </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Between 1996 and 2010, 637 patients underwent 658 redo mitral valve operations; 138 of them had pulmonary hypertension. The mean patient age was 61.3 (13.9) years, with mean left ventricular ejection fraction of 47.6% (13.2%). The mean systolic pulmonary artery pressure was 61.5 (16.8) mm Hg, and mean pulmonary artery pressure was 40.8 (11.6) mm Hg. Patients had one (71%, 98/138), two (23.9%, 33/138), and three (5.1%, 7/138) previous mitral valve operations. Thirty-day mortality was 10.1% (14/138). Multivariate predictors of 30-day mortality were chronic renal failure [odds ratio (OR), 8.041; P = 0.022], peripheral vascular disease (OR, 5.976; P = 0.025), previous mitral valve replacement (OR, 9.034; P = 0.014), and increasing age (OR, 1.077; P = 0.013). The severity of pulmonary hypertension did not impact 30-day ( P = 0.314) or late mortality ( P = 0.860). Kaplan-Meier survival rates at 1, 3, and 5 years were 76.6% (n = 99), 65.7% (n = 62), and 55.9% (n = 41), respectively. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Patients with pulmonary hypertension that undergo redo mitral valve surgery have a 55.9% 5-year survival rate. Increasing age, chronic renal insufficiency, peripheral vascular disease, and preexisting mitral valve prosthesis are associated with early mortality. The severity of pulmonary hypertension does not affect operative mortality rates, but it may decrease 1-, 3-, and 5-year survival. </jats:p></jats:sec>

Transseptal Transcatheter Mitral Valve Replacement for Post-Surgical Mitral Failures

“…The 30-day mortality rate for redo-mitral valve replacement was 10.1 % and the mortality for the percutaneous cohort is 8 %, illustrating the burden of comorbidities of the patient population. 6,35 While this singlecentre series encompasses most of the major complications, the prospect of late migration with subsequent embolisation remains a concern. 36 To address this issue, operators have advocated implanting the THV on the ventricular side of the prosthesis or ring and flare this side to prevent migration.…”

“…5 Elderly patients with significant prosthetic mitral valve disease are often non-ideal candidates for cardiac surgery as advanced age, multiple comorbidities and prior sternotomies can elevate the risk of mitral valve replacement to 7.4-15.1 % mortality. [6][7][8] In fact, in a multivariable analysis, independent predictors of in-hospital mortality, including New York Heart Association III and IV symptoms (OR 3.19; p=0.012) as well as more than re-operation (OR 2.59; p=0.058). 7 In another retrospective analysis of elderly patients with mitral valve surgery, previous mitral valve replacement increased the 30-day mortality rate nine-fold (p=0.013).…”

“…[6][7][8] In fact, in a multivariable analysis, independent predictors of in-hospital mortality, including New York Heart Association III and IV symptoms (OR 3.19; p=0.012) as well as more than re-operation (OR 2.59; p=0.058). 7 In another retrospective analysis of elderly patients with mitral valve surgery, previous mitral valve replacement increased the 30-day mortality rate nine-fold (p=0.013). Moreover, 30-day mortality was compounded by chronic renal failure (OR 8.041; p=0.022), peripheral vascular disease (OR 5.976; p=0.025) and increasing age (OR 1.077; p=0.013), all of which frequently complicate the clinical course of elderly patients.…”

“…Moreover, 30-day mortality was compounded by chronic renal failure (OR 8.041; p=0.022), peripheral vascular disease (OR 5.976; p=0.025) and increasing age (OR 1.077; p=0.013), all of which frequently complicate the clinical course of elderly patients. 6 Degenerative changes in surgically repaired mitral valves or valve replacements can result in severe regurgitation or stenosis-causing symptomatic heart failure. Degeneration of such surgical repairs may present with up to 25 % moderate-severe mitral regurgitation within 3-4 years post-repair and most bioprosthetic mitral prostheses sustain 10-15 years usage before degenerating.…”

Validating a prediction modeling tool for left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR)

“…Elderly patients with severe calcific native mitral valve disease or failing surgical mitral prostheses are often not‐ideal candidates for cardiac surgery as advanced age, multiple comorbidities and prior sternotomies can elevate the risk of mitral valve replacement to 7.4–15.1% mortality . Percutaneous prosthetic valve implantation at the mitral position for degenerated native, repaired, or prosthetic mitral valves is a burgeoning technique, but can be complicated by significant or even fatal left ventricular outflow tract (LVOT) obstruction .…”