Elevated transpulmonary gradient (>12 mmHg) before restrictive mitral annuloplasty was associated with worse postoperative hemodynamics and increased adverse events (HR 2.9; 95% CI 1.2-6.9; P=0.017).
Cohort (n=64)
Does an elevated trans-pulmonary gradient worsen postoperative pulmonary hemodynamics and clinical outcomes in patients with severely impaired left ventricular function and pre-existing pulmonary hypertension undergoing restrictive mitral annuloplasty?
In patients with advanced cardiomyopathy and pre-existing pulmonary hypertension undergoing restrictive mitral annuloplasty, an elevated trans-pulmonary gradient (>12 mmHg) is associated with worse postoperative pulmonary hemodynamics and a significantly increased risk of mortality or heart failure readmission.
Tasa de eventos absoluta: 84% vs 38%
valor p: p=<0.001
Background: This study retrospectively examined the association between elevated trans-pulmonary gradient (TPG), which reflects pre-capillary contribution to pulmonary hypertension (PH), and postoperative pulmonary hemodynamics and outcomes following restrictive mitral annuloplasty (RMA) in patients with pre-existing PH.Methods: Pre- and postoperative (1 month) cardiac catheterization was performed in 64 patients with severely impaired left ventricular function (i.e., ejection fraction ≤40%) and pre-existing PH (mean pulmonary artery pressure (PAP) ≥25 mmHg) who underwent RMA. Patients were segregated into two groups: low TPG (≤12 mmHg) and elevated TPG (>12 mmHg). The mean follow-up period was 54±27 months. The primary outcome seen was a change in pulmonary hemodynamics after RMA; secondary outcomes were composite adverse events, including all-cause mortality and readmission for heart failure.Results: Compared to the low TPG group, patients in the elevated TPG group were more likely to show a postoperative mean PAP of ≥25 mmHg (84% vs. 38%), TPG of >12 mmHg (79% vs. 11%), and pulmonary vascular resistance of ≥240 dynes/sec/cm−5 (84% vs. 6.7%) (all P<0.001), although both groups showed comparable degrees of mitral regurgitation improvement. Serial echocardiography demonstrated that Doppler-derived systolic PAP, which once decreased in both groups, remained stable in the low group while steadily increasing in the elevated group (group effect P<0.001). Patients with elevated TPG had lower freedom from composite adverse events (5-year, 20% vs. 70%, P=0.003). After adjusting for baseline covariates, the elevated TPG was independently associated with increased risk of adverse events (adjusted hazard ratio 2.9, 95% CI: 1.2–6.9, P=0.017).Conclusions: Elevated TPG negatively affects postoperative pulmonary hemodynamics and late outcomes in patients with advanced cardiomyopathy and pre-existing PH who have undergone RMA. These findings suggest that the assessment of TPG should be included in post-RMA risk stratification.
Kainuma et al. (Sat,) conducted a cohort in severely impaired left ventricular function and pre-existing pulmonary hypertension (n=64). Elevated transpulmonary gradient (>12 mmHg) vs. Low transpulmonary gradient (≤12 mmHg) was evaluated on change in pulmonary hemodynamics after RMA (postoperative mean PAP ≥25 mmHg) (p=<0.001). Elevated transpulmonary gradient (>12 mmHg) before restrictive mitral annuloplasty was associated with worse postoperative hemodynamics and increased adverse events (HR 2.9; 95% CI 1.2-6.9; P=0.017).
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