Skip to main content
SpringerLink
Log in

Management of Severe Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery

  • Valvular Heart Disease (J Passeri, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Pulmonary hypertension (PH) is simply defined as a mean pulmonary artery pressure greater than 25 mmHg at rest; however, may result from varying combinations of abnormal pulmonary artery (PA) blood flow, pulmonary vascular resistance (PVR), PA compliance, and pulmonary venous pressure. Mitral regurgitation (MR) allows for partial transmission of systemic arterial pressure into the pulmonary venous system. Mitral stenosis (MS) prevents pulmonary venous drainage into the left ventricle. In either case, the direct result is marked pressurization of the pulmonary venous system, with the primary cause of PH in significant mitral valve disease (PHMVD) being pulmonary venous hypertension (PVH). Chronic and severe PVH may then lead to muscularization of the pulmonary arterial bed, with a rise in PVR and loss of pulmonary arterial compliance that follows (“reactive” pulmonary vascular disease). Right heart dysfunction ensues once the PVR rises and the compliance falls to a point in which the right ventricle (RV) cannot overcome the increased afterload. However, it is worth emphasizing that in the setting of PHMVD, no matter the degree of mismatch between RV afterload and RV function, the root condition in the patient and cause of the PH remains severe MV disease. Without correction of the primary condition, the patient’s heart failure (HF), PH, PVR, and RV dysfunction will remain or progress. Moreover, direct PH medical therapies are ineffective and may actually worsen left heart congestion in the setting of unremediated MVD. Therefore, although surgery may be a higher risk in some patients with PHMVD, the potential benefits justify the risks in the majority of cases. If needed, direct medical management of PH is far simpler and more effective once the MVD is corrected, given the degree of left heart congestion often improves dramatically. Therefore, corrective mitral valve intervention should be considered as the main and definitive treatment for these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Chen J et al. National trends in heart failure hospital stay rates, 2001 to 2009. J Am Coll Cardiol. 2013;61(10):1078–88.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Chen J et al. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998–2008. JAMA. 2011;306(15):1669–78.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Cappola TP et al. Pulmonary hypertension and risk of death in cardiomyopathy: patients with myocarditis are at higher risk. Circulation. 2002;105(14):1663–8.

    Article  PubMed  Google Scholar 

  4. Drazner MH et al. Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant. 1999;18(11):1126–32.

    Article  CAS  PubMed  Google Scholar 

  5. Stevenson WG et al. Improving survival for patients with advanced heart failure: a study of 737 consecutive patients. J Am Coll Cardiol. 1995;26(6):1417–23.

    Article  CAS  PubMed  Google Scholar 

  6. Tedford RJ et al. Pulmonary capillary wedge pressure augments right ventricular pulsatile loading. Circulation. 2012;125(2):289–97.

    Article  PubMed Central  PubMed  Google Scholar 

  7. Butler J, Chomsky DB, Wilson JR. Pulmonary hypertension and exercise intolerance in patients with heart failure. J Am Coll Cardiol. 1999;34(6):1802–6.

    Article  CAS  PubMed  Google Scholar 

  8. Champion HC, Michelakis ED, Hassoun PM. Comprehensive invasive and noninvasive approach to the right ventricle-pulmonary circulation unit: state of the art and clinical and research implications. Circulation. 2009;120(11):992–1007.

    Article  PubMed  Google Scholar 

  9. Mullens W et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol. 2009;53(7):589–96.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Meyer P et al. Effects of right ventricular ejection fraction on outcomes in chronic systolic heart failure. Circulation. 2010;121(2):252–8. The article is presents prognostic implications of right ventricle dysfunction in patient with heart failure and in those with pulmonary hypertension.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Abramson SV et al. Pulmonary hypertension predicts mortality and morbidity in patients with dilated cardiomyopathy. Ann Intern Med. 1992;116(11):888–95.

    Article  CAS  PubMed  Google Scholar 

  12. Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nat Rev Cardiol. 2011;8(3):162–72.

    Article  PubMed  Google Scholar 

  13. Nkomo VT et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005–11.

    Article  PubMed  Google Scholar 

  14. Laslett LJ et al. The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology. J Am Coll Cardiol. 2012;60(25 Suppl):S1–49.

    Article  PubMed  Google Scholar 

  15. Bland EF, Duckett Jones T. Rheumatic fever and rheumatic heart disease; a twenty year report on 1000 patients followed since childhood. Circulation. 1951;4(6):836–43.

    Article  CAS  PubMed  Google Scholar 

  16. Ward C, Hancock BW. Extreme pulmonary hypertension caused by mitral valve disease. Natural history and results of surgery. Br Heart J. 1975;37(1):74–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  17. Barbieri A 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(6):751–9.

    Article  PubMed  Google Scholar 

  18. Guazzi M, Arena R. Pulmonary hypertension with left-sided heart disease. Nat Rev Cardiol. 2010;7(11):648–59.

    Article  PubMed  Google Scholar 

  19. Rosenhek R et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006;113(18):2238–44.

    Article  PubMed  Google Scholar 

  20. Grossman W. Profiles in valvular heart disease, in cardiac catheterization and angiography. Third edition. 1986.

  21. Selzer A, Katayama F. Mitral regurgitation: clinical patterns, pathophysiology and natural history. Medicine (Baltimore). 1972;51(5):337–66.

    Article  CAS  Google Scholar 

  22. Selzer A, Cohn KE. Natural history of mitral stenosis: a review. Circulation. 1972;45(4):878–90.

    Article  CAS  PubMed  Google Scholar 

  23. Kitabatake A et al. Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique. Circulation. 1983;68(2):302–9.

    Article  CAS  PubMed  Google Scholar 

  24. Arkles JS et al. Shape of the right ventricular Doppler envelope predicts hemodynamics and right heart function in pulmonary hypertension. Am J Respir Crit Care Med. 2011;183(2):268–76. This study described the association between transthoracic echocardiography-Doppler findings, especially the presence and characteristic of right ventricle envelope shape and pulmonary vascular resistance.

    Article  PubMed  Google Scholar 

  25. Mauritz GJ et al. Progressive changes in right ventricular geometric shortening and long-term survival in pulmonary arterial hypertension. Chest. 2012;141(4):935–43.

    Article  PubMed  Google Scholar 

  26. Braunwald E et al. Effects of mitral-valve replacement on the pulmonary vascular dynamics of patients with pulmonary hypertension. N Engl J Med. 1965;273:509–14.

    Article  CAS  PubMed  Google Scholar 

  27. Dalen JE et al. Early reduction of pulmonary vascular resistance after mitral-valve replacement. N Engl J Med. 1967;277(8):387–94.

    Article  CAS  PubMed  Google Scholar 

  28. Nishimura RA et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57–185. The paper presents the current guidelines for management of valvular heart disease, even in the presence of pulmonary hypertension.

    Article  PubMed  Google Scholar 

  29. Crawford MH et al. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation. 1990;81(4):1173–81.

    Article  CAS  PubMed  Google Scholar 

  30. Siegel RJ et al. The acute hemodynamic effects of MitraClip therapy. J Am Coll Cardiol. 2011;57(16):1658–65.

    Article  PubMed  Google Scholar 

  31. Goldstone AB et al. Incidence, epidemiology, and prognosis of residual pulmonary hypertension after mitral valve repair for degenerative mitral regurgitation. Am J Cardiol. 2011;107(5):755–60.

    Article  PubMed  Google Scholar 

  32. Rottlaender D et al. Clinical impact of atrial fibrillation in patients with pulmonary hypertension. PLoS One. 2012;7(3):e33902.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Li M et al. Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement. J Am Coll Cardiol. 2005;45(7):1034–40.

    Article  PubMed  Google Scholar 

  34. Loh E et al. Cardiovascular effects of inhaled nitric oxide in patients with left ventricular dysfunction. Circulation. 1994;90(6):2780–5.

    Article  CAS  PubMed  Google Scholar 

  35. Califf RM et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure: the Flolan International Randomized Survival Trial (FIRST). Am Heart J. 1997;134(1):44–54.

    Article  CAS  PubMed  Google Scholar 

  36. Palmer SM et al. Massive pulmonary edema and death after prostacyclin infusion in a patient with pulmonary veno-occlusive disease. Chest. 1998;113(1):237–40.

    Article  CAS  PubMed  Google Scholar 

  37. Humbert M et al. Pulmonary edema complicating continuous intravenous prostacyclin in pulmonary capillary hemangiomatosis. Am J Respir Crit Care Med. 1998;157(5 Pt 1):1681–5.

    Article  CAS  PubMed  Google Scholar 

  38. Preston IR et al. Pulmonary edema caused by inhaled nitric oxide therapy in two patients with pulmonary hypertension associated with the CREST syndrome. Chest. 2002;121(2):656–9.

    Article  PubMed  Google Scholar 

  39. Fattouch K et al. Inhaled prostacyclin, nitric oxide, and nitroprusside in pulmonary hypertension after mitral valve replacement. J Card Surg. 2005;20(2):171–6.

    Article  PubMed  Google Scholar 

  40. Corbin JD et al. High lung PDE5: a strong basis for treating pulmonary hypertension with PDE5 inhibitors. Biochem Biophys Res Commun. 2005;334(3):930–8.

    Article  CAS  PubMed  Google Scholar 

  41. Gómez-Sánchez MA et al. Pilot assessment of the response of several pulmonary hemodynamic variables to sublingual sildenafil in candidates for heart transplantation. Eur J Heart Fail. 2004;6(5):615–7.

    Article  Google Scholar 

  42. Alaeddini J et al. Efficacy and safety of sildenafil in the evaluation of pulmonary hypertension in severe heart failure. Am J Cardiol. 2004;94(11):1475–7.

    Article  CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Carlos D. Davila and Paul R. Forfia each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA

    Carlos D. Davila MD

  2. Temple Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA

    Paul R. Forfia MD

  3. Pulmonary Hypertension, Right Heart Failure, and PTE Program, Temple University Hospital, 3401 N. Broad St - 9th Floor Parkinson - Suite 945, Philadelphia, PA, 19140, USA

    Paul R. Forfia MD

Authors
  1. Carlos D. Davila MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul R. Forfia MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul R. Forfia MD.

Additional information

This article is part of the Topical Collection on Valvular Heart Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Davila, C.D., Forfia, P.R. Management of Severe Pulmonary Hypertension in Patients Undergoing Mitral Valve Surgery. Curr Treat Options Cardio Med 17, 26 (2015). https://doi.org/10.1007/s11936-015-0382-1

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-015-0382-1

Keywords

Search

Navigation