Mitral ve Triküspit Kapak Cerrahisi Öncesi Yapılan Kalp Kateterizasyonu ile Ölçülen Transpulmoner Gradiyentin İntraoperatif, Postoperatif Sağkalım ve Ekokardiyografi Parametreleri Üzerine Etkisinin Değerlendirilmesi

Abstract

Pulmonary Hypertension (PH) is a common complication in patients with mitral valve pathologies. Patients with symptomatic severe mitral stenosis and mitral regurgitation are often treated with surgical valve replacement. This study aimed to investigate the effect of transpulmonary gradient (TPG), measured by preoperative cardiac catheterization, on postoperative mortality and changes in pulmonary pressure. The study included 91 patients [77 (84.6%) females, median age 65 (range: 30-81) years] who underwent mitral valve replacement between 01.01.2015 and 01.12.2022, and had preoperative cardiac catheterization data available. Moderate or greater mitral regurgitation was present in 82 (90.1%) of the patients, and 77 (84.6%) had moderate or greater tricuspid regurgitation. The prevalence of PH in the study population was 96.7%, with a median TPG of 12 mmHg. During the one-year follow-up period, 15 patients (% 16.5) died from all causes. When evaluating one-year mortality, a TPG threshold of 14.5 mmHg predicted mortality with %80 sensitivity and %74 specificity (AUC: 0.796; 95% CI: 0.662-0.929; p: 0.001). In multivariate logistic regression analysis, biological mitral valve (OR: 10.549; CI: 1.825-60.984; p: 0.008) and TPG value (OR: 1.277; CI: 1.044-1.562; p: 0.018) were found to be independent risk factors for one-year mortality. When patients who underwent metallic tricuspid valve replacement and those who died without having an echocardiography were excluded, it was observed that systolic pulmonary artery pressure (SPAP) decreased in 63 patients (80.8%), remained unchanged in 5 patients (6.4%), and increased in 10 patients (12.8%) compared to preoperative values. When divided into two groups based on the direction of SPAP change, no relationship was found between the direction of SPAP change and TPG. The TPG values were similar between the two groups (12 mmHg and 11 mmHg). A significant but weak correlation was observed between the percentage change in SPAP and TPG (p: 0.014 and r: -0.277). This correlation was mainly due to the group with decreased SPAP (p: 0.001 and r: -0.411). Patients with higher TPG values showed a greater percentage decrease in SPAP after surgery. It was also observed that there were differences in the transmitral gradient measured postoperatively between patients with decreased and those without decreased SPAP. Multivariate analysis showed that postoperative transmitral peak gradient was effective in predicting the direction of SPAP change, with a peak gradient of 13.5 mmHg (AUC: 0.739; 95% CI: 0.613-0.865; p=0.004) and a mean gradient of 5.5 mmHg (AUC: 0.678; 95% CI: 0.539-0.817; p=0.033) being significant thresholds for determining the direction of SPAP change postoperatively. In conclusion, patients with a TPG value below 14.5 mmHg and those with a postoperative transmitral peak gradient below 13.5 mmHg and a mean gradient below 5.5 mmHg were observed to be the group most likely to benefit from surgery in terms of both SPAP reduction and mortality.