Mohamed Eid Fawzy, FRCP, FACC, FESC October 6 University Cairo, EGYPT

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Mohamed Eid Fawzy, FRCP, FACC, FESC October 6 University Cairo, EGYPT Prevalence of Severe Pulmonary Hypertension in 531 Consecutive Patients with Severe Mitral Stenosis, Impact of Mitral Balloon Valvuloplasty on Severe Pulmonary Hypertension and Concomitant Severe Tricuspid Regurgitation Mohamed Eid Fawzy, FRCP, FACC, FESC October 6 University Cairo, EGYPT

Objectives The prevalence of severe pulmonary hypertension (P.H.T) in patients with severe mitral stenosis (M.S) remains unknown. The aim of this study is to identify the prevalence of severe pulmonary hypertension in 531 consecutive patients with severe (MS) and evaluate the impact of mitral balloon valvuloplasty (M.B.V) on severe pulmonary hypertension and concomitant severe tricuspid regurgitation (TR).

Methods MBV was successfully performed in 531 consecutive patients. Of these patients, 82 patients (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest >65 mmHg, compared to the remaining 449 patients, who served as controls (group B).

Methods Cardiac Catheterization Right and left cardiac catheterization were carried out, the following hemodynamic measurements were obtained before and immediately after MBV using Inoue Balloon Technique. The pulmonary artery systolic (PAP) and mean pressure, cardiac index (C.I), mitral mean gradient, left atrial pressure (LAP), pulmonary vascular resistance (PVR), mitral valve area (MVA) were calculated using A. Micro-Siemens Computer (manufactured by Siemens-Elema A.B.,Solna, Sweden).

ECHOCARDIOGRAPHIC EXAMINATION All patients underwent Echo and Doppler study before MBV, immediately after and at 3 months and yearly there after. The mitral mean gradient (MG), MVA, pulmonary artery systolic pressure were calculated.

Statistical Analysis Invasive and echocardiographic data obtained before and immediately after MBV, and also at long-term follow up, were compared using Student’s t-test (paired, two-tailed) for continuous data. Kaplan-Meier estimates were used to determine freedom from restenosis and event-free survival (survival with freedom from redo MBV, MVR, cardiac death or NYHA class III or IV) for both groups. Only patients with successful MBV were included in the analysis.

Results No immediate or late death was encountered. Severe pulmonary hypertension was encountered in 82 pts (15%) PAP > 65 mmHg.

Patient baseline characteristics. _________________________________________________________ Parameter Group A Group B p-value (n = 82) (n = 449) _________________ 15%___________________________ Age (years)* 29 ± 9.6 32 ± 11 0.54 Female gender (n) 67 (82) 318 (71) 0.042 Echo score* 8.4 ± 0.9 7.98 ± 1.1 0.0044 Previous surgery (n) 4 22 Tricuspid regurgitation (n) Moderate 33 (40%) 42 (9.3) <0.0001 Severe 10 (12%) 20 (4.4) <0.001 Baseline catheter MR (n) Grade 072 373 Grade +1 10 76 0.76 Baseline atrial fibrillation (n) 10 (12%) 61(13.5%) 0.73 Pregnant (n) 14 (17%) 15 (3.3%) 0.0006 *Value are mean ± SD. Values in parentheses are percentages.

Baseline and immediately post-MBV catheter hemodynamic results. ________________________________________________________________ Parameter Group A (Group B) p-value (n = 82) (n = 449) ___________________________ _ (15%)__________________________________ Mean LAP (mmHg) Baseline 28 ± 4.9 25.6 ± 4.6 <0.0001 Post-MBV 15.4 ± 4.5*** 14.7 ± 3.65*** 0.13 Mitral mean gradient (mmHg) Baseline 14.6 ± 3.8 14.4 ± 2.2 0.30 Post-MBV 5.6 ± 2.2*** 5.4 ± 2.0*** 0.30 Mitral valve area cm2 Baseline 0.72 ± 0.17 0.86 ± 0.19 < 0.0001 Post-MBV 1.7 ± 0.44*** 1.85 ± 0.54*** 0.007 Cardiac index (l/min/m2) Baseline 2.29 ± 0.43 2.45 ± 0.48 0.005 Post-MBV 2.86 ± 0.76*** 2.95 ± 0.75*** 0.30 PASP (mmHg) Baseline 77.6 ± 22.3 45 ± 12.1 < 0.0001 Post-MBV 58 ± 17.7*** 37 ± 9.8*** < 0.0001 PVR (dyne/s/cm-5) Baseline 612 ± 393 211 ± 183 < 0.0001 Post-MBV 477 ± 350** 195 ± 151** < 0.0001 Mitral regurgitation (grade) 0 60 348 1 18 (22%) 103 (23%) 0.90 2 4 (4.8%) 28 (5.7%)

Baseline, immediately post-MBV and final follow up echocardiographic data _______________________________________________________________ Group A Group B p-value (n = 82) (n = 449) Doppler mean gradient (mmHg) Baseline 15.2 ± 2.4 13.2 ± 2.6 <0.0001 Post-MBV 5.4 ± 1.3*** 5.2 ± 1.4*** 0.06 Follow up 6.9 ± 3.4* 6 ± 3*** 0.08 Doppler MVA (cm2) Baseline 0.84 ± 0.16 0.92 ± 0.17 <0.0001 Post-MBV 1.97 ± 0.24*** 1.98 ± 0.28*** 0.81 Follow up 1.55 ± 0.16*** 1.54 ± 0.4*** 0.93 2D echo MVA (cm2) Baseline 0.85 ± 0.16 0.92 ± 0.17 0.0001 Post-MBV 1.88 ± 0.18*** 1.97 ± 0.3*** 0.01 Follow up 1.53 ± 0.48*** 1.6 ± 0.40*** 0.13 Doppler PASP (mmHg) Baseline 79 ± 14 42 ± 9.2 <0.0001 Follow up 36.7 ± 7.53*** 31 ±8.4*** 0.008 Severe TR Baseline 10 (12%) 20 (4%) <0.0001 Follow up 0 10 (2%) 0.008 Moderate TR Baseline 33 (40%) 42(9%) 0.544 Follow up 12 (14%) 34 (7%) -

Procedure-related complications (n = 531) _________________________________________________________ Parameter Group A Group B p-value (n = 82) (n = 449) Mortality 0 0 Post-procedure ASD 25 (30%) 113 (25%) 0.23 Cerebral embolism 0 3 NS Pericardial tamponade 0 5 NS Values in parentheses are percentages. ASD: Atrial septal defect; NS: No significant difference.

Ao → Ao → PA → PA → Before M.B.V. Immediately After

Conclusion The prevalence of severe pulmonary hypertension in patients with severe M.S was 15%. M.B.V is a safe and effective technique in treating patients with severe M.S with severe pulmonary hypertension, the latter condition being normalized over 6-12 months period with regression of concomitant severe TR.