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PAH Specific Therapy for Post Mitral Valve Replacement Pulmonary Hypertension

Demir Baykal


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Conference: 2012 International PHA Conference and Scientific Sessions

Release Date: 06.22.2012

Presentation Type: Abstracts

Demir Baykal, MD, FACC, FASE

Gwinnett Consultants in Cardiology, Lawrenceville GA

OBJECTIVEThe pathological process leading to Pulmonary Arterial Hypertension (PAH) may continue to progress even after initial hemodynamic insult to pulmonary vasculature is eliminated with mitral valve repair or replacement. We propose that after excluding pulmonary venous hypertension diligently, ERAs can be safely used for the treatment of post mitral valve surgery PAH with efficacy.

METHODWe report 4 patients, 3 with MV ring repair and 1 with mechanical prosthetic valve replacement with trace or mild residual mitral regurgitation in all cases. All 4 had mild pulmonary hypertension prior to mitral valve surgery, SPAP 40- 46mmHg with echocardiography. After initial normalization (<36mmhg )or stabilization of SPAPs,within 6 to 24 months mean PA pressures started escalating to 36,40,42 and 55mmHg at the time of heart catheterization of each patient(Table 1) .They were all NYHA class 3 or 4. Patients were eligible for ERA antagonist therapy if they met the echocardiographic and strict hemodynamic criteria with right and left heart catheterization (PCWP or LVEDP <15mmhg and mean PA pressure >25mmHg).Pre determined echocardiographic criteria were mid or late systolic notching of RVOT flow velocity spectrum and mitral E/E’ <16. Repeat right heart catheterizations were done 3 months after the initiation of PAH specific therapy.

RESULTSAll 4 improved similar to WHO group 1 patients reported earlier with 3 of them changing to NYHA class 2 from class 3 and 1 from NYHA class 4 to class 3. The mean decrement in mean PA was 12mmhg, largest change being in the patient with highest pretreatment PA pressure. The mean change in PVR was 1.7 woods units, in commensurate with prior reports for WHO group 1 patient.

CONCLUSIONSelective use of ERA s for post mitral valve surgery WHO group 2 PAH patients is safe and can be very efficacious

                                  Pre                  Post

Pre               Post

Pre                 Post

Pre                 Post

Mean PAp,mmHg

36                    26

40                   28

42                    34

55                   36

PVR, Woods Unit

4.6                  3.8

4.8                 3.6

5.4                   4.2

7.5                 3.8

CI L/min/m2

2.2                  2.5

2.1                 2.6

2.0                   2.4

1.9                 2.6

NYHA, class

2                       3

2                      3

2                       3

2                     3

 Table 1