Minimally invasive mitral surgery in patients with high pulmonary artery pressure: Results of a multicenter observational study

Objectives Pulmonary hypertension is diagnosed in 40% to 75% of patients affected by mitral valve diseases. Little is known regarding outcomes of patients with pulmonary hypertension undergoing mitral valve oeprations through minimally invasive approaches. This study compares the characteristics and in-hospital outcomes of patients undergoing minimally invasive mitral valve surgery, stratified by systolic pulmonary artery pressure. Methods This multicenter, retrospective, prospective, observational study included adults undergoing mitral valve operations through a right minithoracotomy with or without tricuspid valve surgery and atrial fibrillation ablation between 2020 and 2024. Comparisons were performed between patients with systolic pulmonary artery pressure less than 31 mm Hg, systolic pulmonary artery pressure 31 to 55 mm Hg, and systolic pulmonary artery pressure more than 55 mm Hg based on European System for Cardiac Operative Risk Evaluation II cutoffs for systolic pulmonary artery pressure categories. Results This analysis included 1121 patients (female, 47.5%; median age, 69 years, interquartile range, 59-77). Median systolic pulmonary artery pressure was 38 mm Hg (interquartile range, 30-50; systolic pulmonary artery pressure <31 mm Hg: n=307, 27.4%; systolic pulmonary artery pressure 31-55 mm Hg: n=152, 55.3%; systolic pulmonary artery pressure >55 mm Hg: n=194, 17.3%). Patients with higher systolic pulmonary artery pressure were older, mainly female, and characterized by more comorbidities including atrial fibrillation and renal disease. A critical perioperative state was diagnosed in 12% of patients with systolic pulmonary artery pressure more than 55 mm Hg ( P < .001). Patients with higher systolic pulmonary artery pressure more frequently underwent mitral valve replacement and tricuspid annuloplasty and experienced more postoperative dialysis and pacemaker implantation but comparable rates of conversions to sternotomy, respiratory and bleeding complications, and in-hospital mortality (systolic pulmonary artery pressure <31 mm Hg: n=3, 1%; systolic pulmonary artery pressure 31-55 mm Hg: n=6, 1%; systolic pulmonary artery pressure >55 mm Hg: n=5, 2.6%; P = .222) compared with patients with lower systolic pulmonary artery pressure. Conclusions Despite a higher preoperative complexity, patients with high systolic pulmonary artery pressure could be considered for minimally invasive mitral valve surgery with acceptable rates of major intraoperative or postoperative complications regardless of their systolic pulmonary artery pressure values.