HIGH-RISK MITRAL-VALVE REPLACEMENT IN SEVERE PULMONARY-HYPERTENSION -30 YEARS EXPERIENCE

Objective: In the past 30 years, 2316 patients underwent mitral valve replacement (MVR) at our institution; 382 of them had severe pulmonary hypertension (pulmonary artery pressure (PAP) > 50 mmHg; pulmonary va scular resistance (PVR), 690 +/- 46 dyn/s per m(2)). We reviewed our e arly and late results in this high-risk subgroup. Methods: We used 336 mechanical and 46 biological devices for MVR. The follow-up was 95%, with an observation period of 3208 patient-years and a mean of 8.4 +/- 0.2 years per patient. The overall early mortality rate was 10.5% (n = 40) and stayed at about the same level over the years, although pati ents characteristics have changed to much older patients and more reop erations. To clarify this fact we divided our data in results accordin g to the decades in which the operations were carried out. The clinica l preoperative status and results were as follows ( P < 0.05; ** P < 0.01 compared with previous decade). In the decades between 1963 and 1 973 (I), 1974 and 1983 (II) and 1984 and 1993 (III) we operated on n = 95 (I), n = 185 (II), and n =102 (III) patients with a mean age of 43 +/- 1 (I), 50 +/- 1* (II), and 58 +/- 1** (III) years. The incidence of reoperations among these patients was 3.2 (I), 4.9 (II), and 22.6% * (III), The early mortalities were 13.7 (I), 8.6* (II) and 10.8% (II I); late mortalities lowered From 5.77 (I), over 4.95 (II), and up to 3.39%* (ml patients/year. The mean functional status according to New York Heart Association (NYHA) class improved from preoperatively 3.0 +/- 0.1 (I), 3.2 +/- 0.1 (II) and 3.3 +/- 0.1 (III) to 2.4 +/- 0.2 (I) , 2.4 +/- 0.1 (II) and 2.3 +/- 0.1 (III) postoperatively, Results: Com pared with routine elective MVR with a mortality rate of 3.6% (P < 0.0 1), early mortality is high. But once the patient survives the periope rative course, late results show no difference compared with patients without pulmonary hypertension. The functional results as: well are no t significantly different. In spite of on average 15 years older multi morbid patients with therefore higher complication rates, early result s improved slightly, which could be explained by better operative tech niques, perioperative; treatment and nursing (online monitoring with i mmediate therapeutic substitution). Surprisingly the increased number of reoperations had no negative impact on patients' outcomes. Conclusi on: According to our results, we recommend MVR in severe pulmonary hyp ertension even in the elderly, with a high but acceptable risk and goo d long-term results, (C) 1998 Elsevier Science B.V. All rights reserve d.