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Ann Thorac Surg 2007;84:85-86
© 2007 The Society of Thoracic Surgeons
Thoracic and Cardiovascular Surgery, University of Florida, 1600 SW Archer Road, Room NG-33, Gainesville, FL 32610
(Email: beavetm{at}surgery.ufl.edu).
In this article, Pai and colleagues [1] describe their institutional experience with aortic valve replacement in the setting of severe pulmonary hypertension. This is a follow-up study of two previous reports from these authors who are now focusing on the pulmonary hypertension cohort. This is a welcome addition to the surgical literature, as there is a paucity of data on this challenging patient population.
The mortality follow-up was obtained from social security numbers and the national death index. Accordingly it is difficult to discern to what degree surgeon selection bias may have played as a role in avoiding unsavory surgical candidates (eg, the patients undergoing aortic valve replacement [AVR] were often younger). Nonetheless, the 30-day mortality in nonoperated patients was striking at 30% compared with operated patients at 8%. Again, astute clinical judgment could partially explain the high early mortality in nonoperated patients and not as the authors suggest "a need for emergent AVR in these patients in view of a 1% per day mortality." However, when the authors stratified patients with propensity analysis according to the likelihood of undergoing AVR they demonstrated a significant survival benefit with surgery. Furthermore, when they censored the early deaths, which should remove those patients who would have been judged to be a prohibitive operative risk, a survival benefit still remained.
The good news for patients with pulmonary hypertension is that if they were successfully managed through surgery there were no significant differences in the Kaplan-Meier survival curves in the patients with severe pulmonary hypertension compared with those without it. The key then is how to safely guide these patients through their perioperative course. There are now numerous adjuncts available including intravenous milrinone, nesiritide, inhaled nitric oxide, and prostacyclin, and on the horizon, intravenous endothelin-1 antagonists. Our group and others have transitioned patients to oral phosphodiesterase inhibitors such as sildenafil [2, 3]. Much work remains to be done in identifying the optimal perioperative treatment strategies in randomized trials, and also in more accurate reporting to the national Society of Thoracic Surgeons’ database to better define the prevalence.
This report probably confirms most surgeons’ inherent bias that this patient group can be operated on with reasonable perioperative mortality. I encourage the authors to share their findings with the cardiology community. As the authors themselves noted, "The majority of decision[s] for nonsurgical management [were] made by the cardiologists in conjunction with the patients presumably assuming they were too sick for surgical therapy." As evidenced by this article, a huge survival benefit is accrued to those patients successfully managed through surgery and they should be counseled accordingly.
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