Minimally Invasive Mitral Surgery in Patients with High Pulmonary Artery Pressure: Results of a Multicenter Observational Study

Objective Pulmonary hypertension (PH) is diagnosed in 40-70% of patients undergoing mitral valve (MV) surgery. Little is known regarding outcomes of MV patients with PH receiving minimally invasive surgery. This study compares characteristics and in-hospital outcomes of patients undergoing minimally invasive MV surgery, stratified by systolic pulmonary artery pressure (PAPs). Methods This multi-centre retrospective-prospective observational study included adults undergoing MV operations through right mini-thoracotomy with/without tricuspid valve surgery and atrial fibrillation ablation between 2020 and 2024. Comparisons were performed between patients with PAPs< 31 mmHg, PAPs 31-55 mmHg, and PAPs>55mmHg based on EuroSCORE II cut-offs for PAPs categories. Results This analysis included 1121 patients (females: 47.5%; median age: 69 years, interquartile range, IQR [59-77]). Median PAPs was 38 mmHg (IQR [30-50]; PAPs<31: n=307, 27.4%; PAPs 31-55: n=152, 55.3%; PAPs>55: n=194, 17.3%). Patients with higher PAPs were older, mainly female, and characterized by more comorbidities including atrial fibrillation and renal disease. A critical peri-operative state was diagnosed in 12% of patients with PAPs>55 mmHg (p<0.001). Patients with higher PAPs underwent more frequently mitral valve replacement and tricuspid annuloplasty and experienced more post-operative dialysis and pacemaker implantation but comparable rates of conversions to sternotomy, respiratory and bleeding complications, and in-hospital mortality (PAPs<31: n=3, 1%; PAPs 31-55: n=6, 1%; PAPs>55: n=5, 2.6%; p=0.222) compared to patients with lower PAPs. Conclusions Despite a higher pre-operative complexity, patients with high PAPs could be considered for minimally invasive MV surgery with acceptable rates of major intra- or post-operative complications regardless of their PAPs values.