Cardiac Surgery| Volume 286, P49-56, June 2023

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Pulmonary Hypertension and Operative Risk in Mitral Valve and Coronary Surgery

Published:February 06, 2023DOI:



      Pulmonary hypertension (PHT) is a known risk factor for coronary artery bypass grafting (CABG), though less well understood for valve operations. We hypothesized PHT is associated with lower risk during mitral valve operations compared to CABG.


      Patients undergoing isolated mitral valve or CABG operations (2011-2019) in a regional Society of Thoracic Surgeons (STS) database were stratified by pulmonary artery systolic pressure (PASP). The association of PASP by procedure type was assessed by hierarchical regression modeling, adjusting for STS predicted risk scores.


      Of the 2542 mitral and 11,059 CABG patients, the mitral population had higher mean STS risk of mortality (3.6% versus 2.4%, P < 0.0001) and median PASP (42 mmHg versus 32 mmHg, P < 0.0001). PASP was independently associated with operative mortality and major morbidity in both mitral and CABG patients. However, for mitral patients a 10-mmHg increase in PASP was associated with lower odds of morbidity (odds ratio: 1.06 versus 1.13), mortality (odds ratio: 1.11 versus 1.18) and intensive care unit time (4.3 versus 7.6 h) compared with CABG patients (interaction terms P < 0.0001). Among mitral patients, median PASP was higher in stenotic versus regurgitant disease (57 mmHg versus 40 mmHg, P < 0.0001). However, there was no differential association of PASP on morbidity or mortality (interaction terms P > 0.05).


      Although mitral surgery patients tend to have higher preoperative pulmonary artery pressures, PHT was associated with a lower risk for mitral outcomes compared with CABG. Further research on the management and optimization of patients with PHT perioperatively is needed to improve care for these patients.

      Graphical abstract


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        • Barbieri A.
        • Bursi F.
        • Grigioni F.
        • et al.
        Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study.
        Eur Heart J. 2011; 32: 751-759
        • Ghoreishi M.
        • Evans C.F.
        • DeFilippi C.R.
        • et al.
        Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: implications for timing of surgery.
        J Thorac Cardiovasc Surg. 2011; 142: 1439-1452
        • Kennedy J.L.
        • LaPar D.J.
        • Kern J.A.
        • et al.
        Does the Society of Thoracic Surgeons risk score accurately predict operative mortality for patients with pulmonary hypertension?.
        J Thorac Cardiovasc Surg. 2013; 146: 631-637
        • Roselli E.E.
        • Abdel Azim A.
        • Houghtaling P.L.
        • Jaber W.A.
        • Blackstone E.H.
        Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement: implications for transcatheter aortic valve replacement.
        J Thorac Cardiovasc Surg. 2012; 144: 1067-1074.e2
        • Thunberg C.A.
        • Gaitan B.D.
        • Grewal A.
        • Ramakrishna H.
        • Stansbury L.G.
        • Grigore A.M.
        Pulmonary hypertension in patients undergoing cardiac surgery: pathophysiology, perioperative management, and outcomes.
        J Cardiothorac Vasc Anesth. 2013; 27: 551-572
        • Yang B.
        • DeBenedictus C.
        • Watt T.
        • et al.
        The impact of concomitant pulmonary hypertension on early and late outcomes following surgery for mitral stenosis.
        J Thorac Cardiovasc Surg. 2016; 152: 394-400.e1
        • Denault A.
        • Deschamps A.
        • Tardif J.C.
        • Lambert J.
        • Perrault L.
        Pulmonary hypertension in cardiac surgery.
        Curr Cardiol Rev. 2010; 6: 1-14
        • Enter D.H.
        • Zaki A.
        • Duncan B.F.
        • et al.
        A contemporary analysis of pulmonary hypertension in patients undergoing mitral valve surgery: is this a risk factor?.
        J Thorac Cardiovasc Surg. 2016; 151: 1288-1297
        • Aris A.
        • Camara M.L.
        As originally published in 1988: long-term results of mitral valve surgery in patients with severe pulmonary hypertension. Updated in 1996.
        Ann Thorac Surg. 1996; 61: 1583-1584
        • Society of Thoracic Surgeons
        Adult Cardiac Surgery Database Data Collection.
        (Available at:)
        • Patel H.
        • Desai M.
        • Tuzcu E.M.
        • Griffin B.
        • Kapadia S.
        Pulmonary hypertension in mitral regurgitation.
        J Am Heart Assoc. 2014; 3: e000748
        • Shahian D.M.
        • O'Brien S.M.
        • Filardo G.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery.
        Ann Thorac Surg. 2009; 88: S2-S22
        • O'Brien S.M.
        • Shahian D.M.
        • Filardo G.
        • et al.
        The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery.
        Ann Thorac Surg. 2009; 88: S23-S42
        • Muller Jr., W.H.
        Pulmonary hypertension and cardiac surgery.
        Am J Surg. 1959; 98: 651-652
        • Litwak R.S.
        • Silvay J.
        • Gadboys H.L.
        • Lukban S.B.
        • Sakurai H.
        • Castro-Blanco J.
        Factors associated with operative risk in mitral valve replacement.
        Am J Cardiol. 1969; 23: 335-348
        • Chaffin J.S.
        • Daggett W.M.
        Mitral valve replacement: a nine-year follow-up of risks and survivals.
        Ann Thorac Surg. 1979; 27: 312-319
        • Simonneau G.
        • Gatzoulis M.A.
        • Adatia I.
        • et al.
        Updated clinical classification of pulmonary hypertension.
        J Am Coll Cardiol. 2013; 62: D34-D41
        • Pichette M.
        • Liszkowski M.
        • Ducharme A.
        Preoperative optimization of the heart failure patient undergoing cardiac surgery.
        Can J Cardiol. 2017; 33: 72-79
        • Camara M.L.
        • Aris A.
        • Padro J.M.
        • Caralps J.M.
        Long-term results of mitral valve surgery in patients with severe pulmonary hypertension.
        Ann Thorac Surg. 1988; 45: 133-136
        • Roques F.
        • Michel P.
        • Goldstone A.R.
        • Nashef S.A.
        The logistic EuroSCORE.
        Eur Heart J. 2003; 24: 881-882
        • O'Brien S.M.
        • Feng L.
        • He X.
        • et al.
        The society of thoracic Surgeons 2018 Adult cardiac surgery risk models: Part 2-statistical methods and results.
        Ann Thorac Surg. 2018; 105: 1419-1428
        • Hawkins R.B.
        • Mehaffey J.H.
        • Mullen M.G.
        • et al.
        A propensity matched analysis of robotic, minimally invasive, and conventional mitral valve surgery.
        Heart. 2018; 104: 1970-1975