World Journal of Cardiovascular Diseases, 2013, 3, 428-432 WJCD
http://dx.doi.org/10.4236/wjcd.2013.37067 Published Online October 2013 (http://www.scirp.org/journal/wjcd/)
The effects of severe aortic stenosis and high pulmonary
artery pressure on aortic valve replacement*
Faruk Toktas1, Arif Gucu1, Gunduz Yumun1, Cuneyt Eris1, Serhat Yalcinkaya2, Mehmet Demir3#,
Tuğrul Goncu1, Senol Yavuz1
1Cardiovascular Surgery Department, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
2Thoracic Surgery Department, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
3Cardiology Department, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
Received 2 July 2013; revised 12 August 2013; accepted 1 September 2013
Copyright © 2013 Faruk Toktas et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Pulmonary hypertension development
in pure severe aortic stenosis is a situation that affects
mortality and morbidity. Material and Methods: Data
from files of 31 patients with systolic pulmonary ar-
tery pressure over 50 mm Hg and with pure severe
aortic stenosis, and underwent aortic valve replace-
ment in our clinic were examined retrospectively.
Results: Preoperative effort capacities of the patients
were evaluated as follows according to NYHA; 4 pa-
tients class 1-2, 16 patients class 3, and 11 patients
class 4. Twenty-five metal, and 6 biologic aortic valves
were used. Postoperative hospital mortality was re-
corded as 12% with 4 patients. Patients were re-
evaluated on the postoperative 2nd and 12th months.
Pulmonary arterial pressure of the patients was mea-
sured using echocardiography. Preoperative average
pulmonary artery systolic pressure was measured as
55 ± 3 mmHg. The average pressure was measured as
41 ± 3 mmHg on the 2nd, and as 37.8 ± 4 mmHg on
the 12th month. The effort capacity evaluation in the
postoperative 2nd month was as follows: 11 patients
class 1-2, 12 patients class 3, and 4 patients class 4.
The effort capacity evaluation conducted in the 12th
month was: 14 patients were class 1-2, 10 patients
were class 3, and 2 patients were class 4. During the
follow-up 1 year, survival rate of the patients was
determined as 83.8% average, 5 year survival rate
was determined as 61.5%. Conclusion: We believe
that AVR may be performed in severe aortic stenosis
cases with high pulmonary pressure with acceptable
ortality, leading to a better quality and longer life. m
Keywords: Aortic Valve Stenosis; Pulmonary
Hypertension; Heart Valve Prosthesis Implantation;
Prognosis
1. INTRODUCTION
Cases with aortic valve area below 0.6 cm2/m2 are ac-
cepted as severe aortic stenosis (AS) [1,2]. In several
publications, it is stated that the natural course of severe
AS is significantly bad [3-5]. Presence of pulmonary
hypertension (PH) in severe aortic stenosis is a prognosis
negative indicator [6]. The negative prognosis indicators
limiting surgery include: narrow aortic valves, left ven-
tricle function disorder, severe aortic stenosis with low
aortic valve gradient, severe aortic stenosis with pulmo-
nary hypertension development, and aortic stenosis with
cardiac arrhythmia [6-8]. Among these risk factors, lesser
and incomprehensive series were published in the litera-
ture in regards to implementation of aortic valve re-
placement (AVR) in pure severe aortic stenosis with
pulmonary hypertension when compared to the other
factors.
In our study, we aimed to assess the effect of pulmo-
nary hypertension development in severe aortic stenosis
on aortic valve surgery results.
2. PATIENTS AND METHODS
Data from the files of the cases underwent aortic valve
replacement with systolic pulmonary pressure over 50
mmHg and with pure severe aortic stenosis, in our clinic
between the years of 1996 and 2011 were examined ret-
rospectively.
The inclusion criteria were:
1) Severe aortic stenosis and pulmonary artery systolic
pressure over 50 mmHg due to aortic stenosis.
*Conflict of interest: none declared.
#Corresponding autho
r
.

F. Toktas et al. / World Journal of Cardiovascular Diseases 3 (2013) 428-432 429
2) Tricuspid regurgitation flow rate higher than 3.8
m/sn.
3) No evidence of additional valve disease except for
tricuspid insufficiency developing secondary to pul-
monary hypertension. [While selecting, cases with mitral
narrowness (valve area larger than 2.5 cm2), more than
first degree mitral insufficiency) or, more than first de-
gree aortic regurgitation were not included in the study
group].
4) No accompanying congenital anomalies.
Patients with former valve surgery, and/or previous
cardio-vascular surgery, were excluded. Those with ac-
companying coronary lesions were included in the study.
During the same session proper grafts were placed in the
required veins and by-pass was conducted. Patients with
developed tricuspid insufficiency were included in the
study. During the same session De Vega annuloplasty
and proper tricuspid annuloplasty were applied to neces-
sary patients.
3. OPERATIVE TECHNIQUE
General anesthesia was administered to the patients
through standard balance anesthesia technique. Propofol,
and dormicum were preferred for the induction of the
patients. Norcuron and/or pancuronium were used as
muscular relaxant. Inhalation anesthetics were used when
required and isofloran, and/or sevorein were preferred.
Fentanyl citrate was used as narcotic analgesic. Upon
anesthesia induction right cardiac catheterization was
implemented in all patients with swan-ganz catheter
(model 131H-7F; Baxter Healthcare Corp., Edwards Div.,
Irvine, Calif.). Pulmonary artery pressure was monitored.
Heparin was given at 3 mg/kg dose, and heparinization
was performed as ACT (activated clotting time) o ver 480
seconds. During our operations (Pemco Inc., Cleveland,
OH, USA) Roller pump, (membranous oxygenator) hol-
low-fiber membrane oxygenator (Edwards VitaleTM, Ed-
wards Lifesciences LLC, One Edwards Way, Irvine, CA,
USA) were used. Medium level hypothermia was used in
the patients (average 30˚C - 32˚C). In cardiac arrest
(Plegisol, Abbott Laboratories, North Chicago, IL) crys-
talloid cardioplegia was used. For maintenance cardiac
arrest was continued through cold blood cardioplegia
with intermittent potassium and sodium bicarbonate ad-
dition in antegrade way with 20 minute in tervals.
After standard cannulation process, cardiopulmonary
bypass was initiated and aortic valve replacement was per-
formed by single stitches by using suture technique with
pledgets 2/0 braided polyester non absorbable stitch.
3.1. Statistical Analysis
Statistical evaluation was conducted by using SPSS 9.0
programs. Student’s t test and X2 tests were used in ana-
lyzing variances. Kaplan-Meier analysis was used for
survival expectation analysis. A p value <0.05 was ac-
cepted as significant.
3.2. Findings
There were 31 patients meeting the inclusion criteria.
Twelve of these patients were female (38.7%), and the
remaining 19 were male (62.3%). Mean ages of the pa-
tients was 53.0 ± 2.3 years (range 38 - 79). Demographic
characteristics of the patients are given in Table 1.
Preoperative effort capacities of the patients were
evaluated as follows according to NYHA: 4 patients
class 1-2, 16 patients class 3, and 11 patients class 4.
During operation, 25 metal aortic valves varying be-
tween 19 - 25 in size from various manufacturers (e.g.
Carbomedix, St-Jude Medical, and Medtronic), and 6
biologic aortic valves were used. In 5 patients, Man-
ouguian procedure for aortic root enlargement was per-
formed due to narrow aortic root. In 12 patients with
coronary artery disease, coronary artery bypass grafts
were added to procedure during the same session. De
Vega Tricuspid annuloplasty was performed using 2/0
prolene in 12 patients with tricuspid insufficiency at 3 - 4
level.
We did not have any perioperative mortality. In one
patient with additional coronary bypass grafting, we
needed intra-aortic balloon pump for pump retrieval.
Average intubation period was 4.5 ± 1 hours. In two
cases we had a prolonged intubation period exceeding 48
hours.
Table 1. Demographic characteristics of the patients.
Demographic characteristics of the patients Values
Age (average) 38 - 79 (53.0 + 2.3)
Gender male/female 12/19
Hypertension 60%
Diabetes 17%
Coronary artery disease 38%
Chest pain (angina) 55%
Renal failure (creatine > 1.8) 27%
Congestive heart failure 55%
Chronic obstructive pulmonary disease (COAH) 12%
Aspirin use 52%
Beta blocker use 22%
Angiotensin converting enzyme inhibitor use 38%
Statin use 27%
Pulmonary artery systolic pressure (mmHg) 55 ± 3

F. Toktas et al. / World Journal of Cardiovascular Diseases 3 (2013) 428-432 430
Pulmonary arterial systolic pressure measurements of
all patients were conducted by swan-ganz catheter placed
upon general anesthesia administration. Measurement
was repeated on the postoperative 24th hour. Pulmonary
arterial systolic pressure measurements and changes are
given in Table 2. Preoperative average pulmonary arte-
rial systolic pressure measurements value was measured
as 55 ± 3 mmHg. There was a difference between the
measurement at preoperative catheter laboratory and
preoperative operation table. Surgery room measure-
ments were taken under general anesthesia, following a
6-hour period of starving, therefore these measurements
were lower. Thus, we used the values measured during
angiography in the study. The postoperative 24 hours
average pulmonary arterial systolic pressure measure-
ments value of the patients was determined as 43 ± 5
mmHg. Variance was calculated as 25.38% (p < 0.001).
Hospital mortality was experienced in 4 patients
(12%). In two cases the cause of death were the pro-
longed intubation due to respiratory failure, and accom-
panying multiple organ failure. One case died during
laparatomy secondary to mesenteric ischemia, and severe
intestinal resection. One case died due to low cardiac
flow.
During the 12-month follow-up, another case died due
to extra cardiac reasons.
Patients were reevaluated in the postoperative 2nd and
12th months. Pulmonary arterial systolic pressure of the
patients were measured using echocardiography (Vivid 7,
GE Medical Systems, Vingmed, Horton, Norway). The
average pulmonary artery systolic pressure were meas-
ured as 41 ± 3 mmHg on the 2nd month, and as 37.8 ± 4
mmHg on the 12th month, respectively.
The average follow-up was 5.2 patient years, and
88.4% of the patients were followed between 6 months
and 13 years. During the follow up period, the 1-year
survival rate was determined as 83.8%, and 5-year sur-
vival rate was determined as 61.5%.
Ejection fractions of the patients were measured on
preoperative, early postoperative (within 2 weeks fol-
lowing surgery), postoperative 2nd month, and 12th
month periods. While the preoperative ejection fraction
average was 38% ± 18%, this value was obtained as 42%
± 23% during early postoperative period, as 43% ± 20%
at the 2nd month, and as 46.6% ± 3% at the 12th month
(Table 2).
Patients were evaluated according to NYHA criteria in
terms of effort capacities during the same period. Results
obtained in the effort capacity evaluation during postop-
erative 2nd month were as follows: 11 patients class 1-2,
12 patients class 3, and 4 patients class 4. During the
effort capacity evaluation at the 12th month 14 patients
were class 1-2, 10 patients were class 3, and 2 patients
were class 4.
4. DISCUSSION
Cases below 0.6 cm2/m2 with valve area in aortic nar-
rowness are accepted as severe aortic stenosis [1,2].
Various publications are available reporting on high
mortality rates for severe aortic stenosis cases when
valve replacement is not conducted [9-11]. Congestive
heart failure emerges significantly in severe aortic steno-
sis cases within average two years [4]. In AS cases, left
ventricle hypertrophy is the reason for severe cardiac
arrhythmia and sudden death [12]. Low left ventricle
ejection fraction in complex and frequent ventricle ar-
rhythmias and increased peak systolic wall stress are
common in Cardiac arrhythmias [13,14]. An important
determinant of sudden death in aortic stenosis is the
pulmonary hypertension developed parallel to left ven-
tricle function disorder [15]. Positive effect of AVR on
patient survival and ejection fraction in severe aortic
stenosis are revealed in several studies [16,17]. Sig-
Table 2. Preoperative postoperative measurements and variances of the patients.
Measured values
Preoperative
average
values n = 31
Postoperative
early period
average value
Postoperative
second month
average value
n = 27
Postoperative
twelfth month
average value
n = 26
Preoperative
measurement-postoperative
12th month measurement
variance rate
p value
Pulmonary artery systolic pressure (mmHg) 58.3 ± 7 43.5±5 41.3 ± 3 37.8 ± 4 35.16% p  0.001
Injection fraction % 34 ± 4.8 42±2.3 43 ± 2.1 46 ± 3.4 34.59% p  0.001
Aortic valve area (cm2) 0.68
Aortic gradient (mmHg) 68 ± 16 22 21 69.19% p  0.001
Septum thickness (cm) 1.5  0.2 cm 1.46  0.3 cm1.38  0.2 cm8% p  0.01
Posterior wall thic kness (cm) 1.2 ± 0.1 cm 1.18  0.2 cm1.16  0.2 cm0.4% p  0.001
Left ventricle end-diastolic diameter (cm ) 5.2 ± 0.8 4 .7 ± 0.8 9.6% p  0.0 01
Tricuspid reg u rgitation flow rate 3.97 ± 0.5 2.7 ± 0.8 29.97% p  0.001

F. Toktas et al. / World Journal of Cardiovascular Diseases 3 (2013) 428-432 431
nificant recovery observed in our study results in terms
of patient ejection fractions. While the preop erative ejec-
tion fraction average was 38% ± 18%, this value was
obtained as 42% ± 23% during early postoperative pe-
riod, as 43% ± 20% at the 2nd month, and as 46.6% ±
3% at the 12th month.
Johnson et al. [18] published the first AVR experience
in severe aortic stenosis cases with severe pulmonary
hypertension in 1988. Later Tracy [19] and Snopek [20]
published the series which were not comprehensive and
with low mortality results. More extensive case series
and randomized studies were conducted by Malouf et al.
In his study, AVR was performed on 37 patients with se-
vere aortic stenosis cases developed severe pulmonary
hypertension were compared to AVR not-implemented
on 10 patients. During the study, operative mortality was
reported as 6 (16%), and late mortality was reported as
9%; total 32% mortalities were reported. Eight of the
patients treated by conservative treatment died (80%). In
our study mortality was 12% and is in accordance with the
mortality rate of severe aortic stenosis with left ventricle
function disorder reported in the literature [8,17,21].
In the comprehensive study conducted by Ramdas et
al. [22] AVR with conducted group and AVR without
conducted group of pati e n t s w ith average age 75, averag e
pulmonary artery pressure 69 mmHg with severe aortic
stenosis were compared. In AVR not conducted group,
1-month mortality was reported 30% and 1-year mortal-
ity was determined as 70%. Renal failure, old age, heart
failure, dementia, low ejection fraction were noted as the
important causes of mortality. In the same study 1-month
mortality rate of AVR conducted group of patients was
8%, 5-year mortality rate was determined as 65%. For
AVR not conducted patients, 5-year survival rate was
20%. These significantly successful results display the
beneficial results of AVR. However, we believe that the
case of Ramdas et al. [22] including the mitral valve at-
tempts in addition to aortic stenosis is an importan t detail.
Implemented mitral valve attempts might affect the re-
veal of the AVR effect on pulmonary hypertension re-
gression.
During the follow-up of medium and severe aortic
stenosis cases with no AVR implementation conducted
by Chizner et al. [3], mortality speed was determined as
follows: 26% for the 1st year, 48% for the 2nd year, and
57% for the 3rd year. In various studies, 5-year mortality
rate differs between 18% - 50% follow-ups of 453 pa-
tients with severe aortic stenosis with no AVR imple-
mentation conducted by Padmini [23] et al. The survival
rates of 1 year, 5 years and 10 years were found respec-
tively as 62%, 32%, and 18%. In our study, 1-year sur-
vival rate was 83.8% and 5-year survival rate was calcu-
lated as 61.5%.
Long follow-up period and long follow-up results of
studies conducted by Ramdas et al. [22] and Malouf et al.
[21] are close to our study, however, the average age is
higher than our study group. The most important reason
why patient average ag e in our study is younger than th at
of other studies is that we face cardiac valve diseases
earlier than Western societies due to common rheumatic
heart diseases in our population. This situation seems to
be the reason why the average age of the patient popula-
tion included in our study is much younger than the se-
ries in the literature. (While the etiology of the aortic
valve disease in our patient group is mostly formed by
rheumatic heart disease, senile degeneration is observed
as the most etiologic factor in the series included in the
literature.) Moreover, survival length of our patients can
be explained by employing relatively younger patient
population.
Today cardiac surgery increases in number and finds a
place for itself in more common and expanded indica-
tions by pushing the limits restricting indications. In
most publications, positive results of eliminatin g the me-
chanical problem in aortic valve are declared almost in
all situations of aortic valve surgery. Most cases scaring
the surgeons are published with tolerable mortality and
morbidities. We believe that AVR with acceptable mor-
tality can be conducted in severe aortic stenosis cases
with high pulmonary pressure and accordingly patients
might have much more qualified and longer lives.
Limitations of the Study
The most important limitation of our study was that the
difference between pulmonary artery pressure levels and
primary pulmonary hypertension could not be deter-
mined clearly. This might have been determined by tak-
ing biopsy from the patients in pulmonary vascular bed,
however, we did not have the chance to execute biopsy.
The small samples sum is another limitation.
The difference between the effect of revascularization
on myocardial performance and clinical regression in the
cases with coronary artery diseases included in the study
could not b e r evealed.
Comparison of our study was conducted in surgical
cases. Comparison with the patients receiving medical
treatment was realized with the help of the results of
medical treatment cases given in the literature.
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ABBREVIATIONS
AS: Aortic stenosis
AVR: Aortic valve replacement
NYHA: New York Heart Association
PH: Pulmonary hypertension