Effect of Pulmonary Hypertension Hemodynamic Presentation on Clinical Outcomes in Patients With Severe Symptomatic Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation

Abstract

P ulmonary hypertension (PH) frequently coexists with severe aortic stenosis (AS) and confers a worse prognosis.1,2 Transcatheter aortic valve implantation (TAVI) is an alternative therapeutic modality to surgical aortic valve replacement (SAVR) for patients with symptomatic severe AS who are either inoperable or high risk for conventional SAVR.3-5 Patient selection for TAVI relies on clinical and anatomic factors, and risk assessment is a critical component of the procedural planning. 6 Previous studies have shown PH to be a predictor of mortality after TAVI. [7][8][9][10][11] However, studies to date have focused mainly on PH severity rather than hemodynamic presentation and used noninvasive measurements of pulmonary artery systolic pressure (PASP), which correlate only modestly with invasive measurements.12 According toBackground-Pulmonary hypertension (PH) frequently coexists with severe aortic stenosis, and PH severity has been shown to predict outcomes after transcatheter aortic valve implantation (TAVI). The effect of PH hemodynamic presentation on clinical outcomes after TAVI is unknown. Methods and Results-Of 606 consecutive patients undergoing TAVI, 433 (71.4%) patients with severe aortic stenosis and a preprocedural right heart catheterization were assessed. Patients were dichotomized according to whether PH was present (mean pulmonary artery pressure, ≥25 mm Hg; n=325) or not (n=108). Patients with PH were further dichotomized by left ventricular end-diastolic pressure into postcapillary (left ventricular end-diastolic pressure, >15 mm Hg; n=269) and precapillary groups (left ventricular end-diastolic pressure, ≤15 mm Hg; n=56). Finally, patients with postcapillary PH were divided into isolated (n=220) and combined (n=49) subgroups according to whether the diastolic pressure difference (diastolic pulmonary artery pressure−left ventricular end-diastolic pressure) was normal (<7 mm Hg) or elevated (≥7 mm Hg). Primary end point was mortality at 1 year. PH was present in 325 of 433 (75%) patients and was predominantly postcapillary (n=269/325; 82%

Response To Letter Regarding Article, “Effect of Pulmonary Hypertension Hemodynamic Presentation on Clinical Outcomes in Patients With Severe Symptomatic Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: Insights From the New Proposed Pulmonary Hypertension Classification”

“…2 We observed that patients with isolated postcapillary PH had clinical outcomes similar to patients without PH, whereas combined postcapillary and precapillary PH was a strong predictor of all-cause mortality at 1 year after adjustment for several comorbidities. 2 We agree with Dr Bishu 1 that raw pulmonary artery systolic pressure (PASP) estimates alone provide prognostic information among patients with severe aortic stenosis undergoing both TAVI and surgical aortic valve replacement as has been shown in several studies.3-6 However, raw PASP estimates provide no information whatsoever about the likely cause of PH. Conversely, by stratifying patients according to hemodynamic presentation, it is possible to differentiate PH because of left heart disease (ie, postcapillary PH or group 2 PH) from other PH subgroups (ie, precapillary PH-groups 1, 3, 4, and 5 PH).…”

Prognostic impact of invasive haemodynamic measurements in combination with clinical and echocardiographic characteristics on two-year clinical outcomes of patients undergoing transcatheter aortic valve implantation

“…It operates the continuum between left ventricular dysfunction and right heart failure in the context of pressure overload: indeed, the backward transmission of the elevated pressures in the hypertrophic left ventricle promotes the remodelling of pulmonary vasculature. The presence of pulmonary hypertension affects the prognosis of patients with severe AS irrespective of the treatment 7,10,11 . In this context, we sought to investigate whether other invasive haemodynamic parameters, among those mirroring the pathophysiology of the valvular disease, could be related to mortality after TAVI.…”

“…In this regard, clinical characteristics and comorbidities at baseline represent the variables with greatest prognostic weight in recently developed scores to predict early and late mortality after TAVI 22 . Previous investigations by our group focused on the effect of haemodynamic patterns of pulmonary hypertension or low-flow, low-gradient aortic stenosis on clinical outcomes after TAVI 7,23 . Instead, the present analysis sought to determine whether preoperative RHC provides additional prognostic value on top of standard, non-invasive evaluation including clinical and echocardiographic parameters.…”

“…Indeed, sustained pressure overload induces the development of myocardial hypertrophy which progressively impairs the diastolic properties of the left ventricle; its heightened filling pressures are then passively transmitted backwards, eliciting a reactive component within the pulmonary vasculature 4 . Multiple lines of evidence support the negative impact of baseline pulmonary hypertension on clinical outcomes after transcatheter aortic valve implantation (TAVI) [5][6][7] .…”

The difficult diagnosis of pulmonary vascular disease in heart failure

“…Furthermore, the right ventricle's functional adaptation to afterload may matter more to prognosis than only PH and related vascular gradients [21,22], and measurements for phenotyping do not solely qualify by prognostic capability [22,23]. In the meantime, several studies have nevertheless confirmed the impact on outcome of an increased DPG in PH-LHD [24][25][26][27].…”