Haemodynamic mechanisms and long‐term prognostic impact of pulmonary hypertension in patients with severe aortic stenosis undergoing valve replacement

Abstract

Aims We aimed to investigate the prevalence, detailed invasive haemodynamics, and prognostic impact of pulmonary hypertension (PH) in severe aortic stenosis (AS). Methods and results We studied 503 patients (mean age 74 ± 10 years) with severe AS (indexed aortic valve area 0.4 ± 0.1 cm2/m2, left ventricular ejection fraction 57 ± 12%) undergoing left and right heart catheterization prior to aortic valve replacement. Median follow‐up was 3.7 (interquartile range 2.6–5.4) years. Baseline PH (mean pulmonary artery pressure ≥ 25 mmHg) was found in 239 (48%) patients: 31 patients had pre‐capillary PH [mean pulmonary artery wedge pressure (mPAWP) ≤ 15 mmHg], 144 had isolated post‐capillary PH [IpcPH; mPAWP > 15 mmHg, pulmonary vascular resistance (PVR) ≤ 3 Wood units (WU)], and 64 had combined pre‐ and post‐capillary PH (CpcPH; mPAWP > 15 mmHg, PVR > 3 WU). Patients with CpcPH had higher mortality than those with IpcPH, pre‐capillary PH, and without PH. In the multivariate analysis, CpcPH remained an independent predictor of death (hazard ratio 4.39, 95% confidence interval 2.40–8.03; P < 0.001). Patients with CpcPH had higher mPAWP (26 ± 7 vs. 22 ± 5 mmHg) and lower pulmonary arterial capacitance (1.5 ± 0.6 vs. 2.9 ± 1.2 mL/mmHg) than IpcPH patients but similar left ventricular end‐diastolic pressure (LVEDP; 25 ± 7 vs. 25 ± 7 mmHg). A smaller LVEDP–mPAWP difference was related to larger left atrial size, atrial fibrillation, and more severe mitral regurgitation. Conclusions In patients with severe AS, PH is common but underlying mechanisms differ. Patients with CpcPH have higher mPAWP, lower pulmonary arterial capacitance, and worse survival than all other groups. Left atrial dysfunction and mitral regurgitation seem to be drivers of high mPAWP in CpcPH.

Relationship between B‐type natriuretic peptide and invasive haemodynamics in patients with severe aortic valve stenosis

“…The study was approved by the local ethics committee. The present study population is a subgroup of a larger cohort we have previously reported on …”

February 2019 at a glance: pathophysiology, exercise capacity, diuretics and valve disease

“…Pulmonary hypertension was found at baseline in 48% of patients, 29% had isolated post‐capillary hypertension, 6% isolated pre‐capillary hypertension, and 13% combined pre‐ and post‐capillary pulmonary hypertension. This latter group had higher pulmonary wedge pressure, lower pulmonary artery capacitance, larger left atrial size, more severe mitral regurgitation and poorer survival at multivariate analysis …”

“…Pulmonary hypertension is a major determinant of outcomes in cardiac patients. 5 -7 Weber et al 8 assessed its prevalence and prognostic impact in 503 patients with severe aortic stenosis undergoing cardiac catheterization prior to aortic valve replacement. Pulmonary hypertension was found at baseline in 48% of patients, 29% had isolated post-capillary hypertension, 6% isolated pre-capillary hypertension, and 13% combined pre-and post-capillary pulmonary hypertension.…”

“…This latter group had higher pulmonary wedge pressure, lower pulmonary artery capacitance, larger left atrial size, more severe mitral regurgitation and poorer survival at multivariate analysis. 8 .…”

Correlation between Doppler echocardiography and right heart catheterization assessment of systolic pulmonary artery pressure in patients with severe aortic stenosis

“…1 Pulmonary hypertension (PH) is a common finding in patients with AS, especially postcapillary PH due to left heart disease, the most common type of PH. [2][3][4][5][6][7][8][9][10][11] Pulmonary hypertension is a sign of advanced cardiac damage due to severity of AS according to damage stages 3 and 4 as described by Genereux et al 12 Previous studies in patients with PH showed an increased mortality after aortic valve replacement (AVR) and PH to be a marker for poor prognosis. 6,7,[9][10][11]13,14 Therefore, assessment of PH is important for risk stratification, with PH being one of the components of the logistic EuroSCORE and the EuroSCORE II.…”