Clinical Significance of Preoperative Pulmonary Artery Hypertension in Patients Undergoing Mitral Valve Replacement for Rheumatic Heart Disease and Its Prognostic Implications

Abstract

Background: Rheumatic heart disease (RHD) is a leading cause of mitral valve pathology globally, frequently complicated by pulmonary arterial hypertension (PAH). The impact of preoperative PAH severity on postoperative outcomes following mitral valve replacement (MVR) needs to be evaluated.
Objectives: To follow the course of preoperative PAH following MVR for RHD, and to assess the effect of PAH severity on postoperative outcomes.
Methods: A single-centre, prospective observational study was conducted at a tertiary care centre. Eighty consecutive patients with RHD undergoing MVR with preoperative PAH (sPAP ≥ 20 mmHg) were enrolled between April 2024 and December 2025. Clinical, echocardiographic, intraoperative and postoperative parameters were recorded at baseline, before discharge, 1 month and 3 months postoperatively. Statistical analysis was performed using repeated measures ANOVA and logistic regression.
Results: The study population had a mean age of 42.8 ± 12.4 years with female predominance (61.2%). Mean baseline sPAP was 43.1 ± 6.0 mmHg, which progressively decreased to 32.5 ± 1.3 mmHg at 3-month follow-up (p < 0.001). Overall in-hospital mortality was 5% (n = 4). Mortality was significantly associated with severe preoperative PAH, advanced right ventricular dysfunction, severe tricuspid regurgitation, NYHA Class III/IV, higher BMI and prolonged operative times (p < 0.001 for all).
Conclusion: MVR effectively reduces PAH in patients with rheumatic mitral valve disease. However, PRE operative right ventricular dysfunctions, rather than PAH severity alone, was the primary determinant of postoperative outcome. Early surgical referral before irreversible right ventricular dysfunction is crucial for optimal outcomes.