Clinical features of late-onset pulmonary hypertension after successful left-sided valve surgery

Background Despite successful left-sided valve surgery with well-functioning prosthetic or repaired valves, some patients subsequently develop dyspnea and pulmonary hypertension (PH), often requiring invasive hemodynamic evaluation. Purpose We aimed to characterize the clinical and hemodynamic features of patients presenting with late-onset PH after uneventful valve surgery. Methods We retrospectively analyzed consecutive patients who underwent comprehensive cardiac catheterization for evaluation of PH after successful left-sided valve surgery from January 2014 to December 2025. PH was defined as a mean pulmonary artery pressure (PAP) >20 mmHg. Results A total of 87 patients (59 women; mean age, 71±9 years; mean PAP, 35±8.5 mmHg) were included. Mitral and tricuspid valve surgery with maze procedure or LA reduction was the most frequent surgery (n=27, 31%), followed by mitral and tricuspid valve surgery (n=12, 13.8%) and mitral valve surgery alone (n=11, 12.6%). All had preserved left ventricular ejection fraction (LVEF, 59.6 ± 4.9%). Cardiac catheterization was performed 10.8 ± 9.2 years after the index valve surgery. Two distinct phenotypes of PH were identified: stiff left atrium syndrome (SLAS; elevated LA pressure with a giant V wave exceeding left ventricular end-diastolic pressure [LVEDP], n=67) and heart failure with preserved LVEF (HFpEF; LVEDP ≥ LA pressure, n=20). Patients with SLAS tended to be older (72±8 vs. 68±9 years, p=0.054), whereas diabetes was more prevalent in the HFpEF group (50.0% vs. 23.9%, p=0.025). The SLAS group had a significantly higher prevalence of prior maze procedure (61.2% vs. 20.0%, p=0.001) and developed PH earlier after surgery, reflected by a shorter interval between surgery and catheterization (9.3 vs. 16.1 years, p=0.003). Although mean LA pressure and PAP were comparable between groups, heart failure-related hospitalization was significantly more frequent in the SLAS group (log rank P = 0.043), while overall mortality did not differ. Conclusions SLAS and HFpEF were two distinct phenotypes associated with late-onset PH after successful left-sided valve surgery. Given the increasing long-term survival after valve surgery, heightened clinical awareness of late-onset PH and its heterogeneous mechanisms is warranted. Further studies are needed to optimize management and improve outcomes in this growing patient population.