Unilateral Pulmonary Edema after Minimally Invasive Mitral Valve Surgery: Preoperative, Intraoperative, and Postoperative Risk Modification?

Objectives: Minimally invasive mitral valve surgery makes it possible to operate on patients with less trauma. Right side unilateral pulmonary edema (ULE) is a rare but clinically important complication, but it is rarely reported. We analyze pre-, intra-, and short postoperative factors that favor ULE occurrence.

Methods: A total of 200 patients with minimally invasive therapy of the mitral valve, possibly the tricuspid valve and any indication-related concomitant atrial ablation in our clinic were analyzed. We collected morbidity-associated and procedure-associated parameters. A univariate and multivariate analysis of the risk was performed.

Result: Patients were 59.9 ± 1.0 years old (59.5% male, BMI: 25.5 ± 5.1 kg/m²). 84.5% received a mitral valve reconstruction, 10% received atrial fibrillation ablation, and 6.5% received tricuspid valve repair. 8% developed ULE, of which 6 patients required ECMO therapy. ULE patients showed longer ventilation times (8.8 ± 8.6 vs. 1.3 ± 1.2) and intensive care stays (11.9 ± 8.8 vs. 4.3 ± 3.2), higher dialysis frequency (40 vs. 4.5%). 4 ULE patients and 5 (2.5%) without died. Risk factors for the genesis of ULE were (univariate [odds]): atrial fibrillation [1.149], COPD [4.638], LVEF reduction [1.06], previous myocardial infarction [6.286], higher NYHA stage [1.630], inflammation (leukocytes [1.128], CRP [1.01]), renal dysfunction (creatinine [1.308], urea [1.021]), mitral valve replacement [7.553], longer surgery times (EKZ [1.02], clamping time [1.021]), norepinephrine requirement [1.053], high ventilation pressures (FiO2 [1.063], PEEP [1.51], Pmax [1.333]), high transfusion requirement (erythrocytes [1.46], platelets [3.066], plasma [2.492]), therapy with coagulation products (fibrinogen [22.8], PPSB [38.444]) and metabolic parameters (high LDL [0.964], triglycerides [1.033],HDL [0.893]). Age, gender, right ventricular parameters, pulmonary artery hypertension, pulmonary fibrosis and diabetes mellitus, increased BMI and type of cardioplegia showed no influence. The multivariate analysis identified [ODDs]: COPD [4.126], mitral valve replacement [3.117], long extracorporal circulation [1.028], norepinephrine dependency [1.044], leukocytosis [1.106], triglyceridemia [1.019], high oxygen demand [1.088], administration of plasma [2.181] and PPSB [10.777] as independent risk factors, sinus rhythm [0.221] was protective with regard to ULE genesis.

Conclusion: A ULE is a life-threatening complication. There are pre-, intra-, and postoperative targets for modifying the procedure and for conditioning the patient to reduce the risk.

Publication History

Article published online:
19 February 2021