Supplementary Material for: Prognostic Implication of Pulmonary Arterial Pressure in Surgical Repair of Predominantly Congenital Mitral Value Regurgitation-based Intracardiac Abnormalities

Background Knowledge is limited regarding the significance of pulmonary arterial pressure (PAP) in predominantly congenital mitral value regurgitation (MR)-based intracardiac abnormalities. Methods From a prospective cohort, we included 200 patients with congenital mitral value regurgitation regardless of other associated intracardiac abnormalities (mean age 60.4 months, 67% female, systolic PAP [sPAP] 54.2 mm Hg) surgically repaired in 2012-2019 and followed up to 2020 (median 30.0 months). Significant pulmonary hypertension (PH) was defined as sPAP > 50 mm Hg at rest or mean PAP > 25 mmHg on right heart catheterization. By perioperative sPAP changes, patients were stratified as Group I (pre-normotension-to-post-normotension), Group II (pre-hypertension-to- post-normotension), or Group III (pre-hypertension-to- post-hypertension). Primary outcomes were the recurrence of MR (defined as the regurgitation grade of moderate or greater) and the progression of MR (defined as any increase in magnitude of regurgitation grade after surgery). Cox proportional hazard and Kaplan-Meier curve was performed. Results There was no association between preoperative PH and the recurrent MR (adjusted hazard ratios [aHR] 1.146 [95% CI 0.453-2.899]) and progressive MR (aHR 1.753 [95% CI 0.807-3.804]), respectively. There were no significant differences among Group I, Group II and Group III in the recurrent MR but in the progressive MR. A dose dependency was identified for preoperative sPAP with the recurrent MR (aHR 1.050 [95% CI 1.029-1.071]) and progressive MR risks (aHR 1.037 [95% CI 1.019-1.055]), respectively. Conclusions Preoperative higher sPAP are associated with worse outcomes, warranting heightened attention to the identification of perioperative sPAP.

目前针对以先天性二尖瓣反流为主的心内异常中，肺动脉压（pulmonary arterial pressure, PAP）的临床意义，相关研究背景知识仍较为有限。
方法 本研究纳入前瞻性队列中2012-2019年接受手术修复的200例先天性二尖瓣反流患者，无论是否合并其他心内异常（患者平均年龄60.4个月，女性占比67%，静息收缩期肺动脉压[systolic PAP, sPAP]为54.2 mmHg），随访至2020年，中位随访时长30.0个月。本研究将显著肺动脉高压（pulmonary hypertension, PH）定义为：静息状态下收缩期肺动脉压>50 mmHg，或经右心导管检测的平均肺动脉压>25 mmHg。根据围手术期sPAP的变化情况，将患者分为三组：第I组（术前血压正常→术后血压正常）、第II组（术前高血压→术后血压正常）以及第III组（术前高血压→术后高血压）。本研究的主要结局指标为二尖瓣反流复发（定义为反流程度达中度及以上）以及二尖瓣反流进展（定义为术后反流程度较前出现任何程度加重）。采用Cox比例风险模型与Kaplan-Meier曲线进行统计分析。
结果 术前肺动脉高压与二尖瓣反流复发（校正后风险比[adjusted hazard ratios, aHR] 1.146，95%置信区间[confidence interval, CI] 0.453~2.899）、二尖瓣反流进展（aHR 1.753，95%CI 0.807~3.804）均无显著关联。三组患者在二尖瓣反流复发率上无显著差异，但在反流进展率上存在差异。术前sPAP水平与二尖瓣反流复发风险（aHR 1.050，95%CI 1.029~1.071）及反流进展风险（aHR 1.037，95%CI 1.019~1.055）均呈剂量依赖性相关。
结论 术前较高的sPAP水平与不良临床结局相关，提示临床应加强对围手术期sPAP监测的重视程度。