Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement

Abstract

Objectives To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality. Methods Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders. Results Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index. Conclusions Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.

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

“…3 There is relatively recent evidence that in patients with severe AS, PH often persists after AVR, 5,6 and that post-AVR PH is a more important prognostic predictor than pre-AVR PH. 5 Since this information is derived from echocardiographic studies, the detailed haemodynamic pattern prior and post AVR of these patients remains unknown. We hypothesize that these patients with persistent PH after AVR may have had CpcPH beforehand but this remains to be shown in future studies.…”

“…In patients with severe aortic stenosis (AS), PH is frequent and a marker of poor prognosis . However, the majority of data on PH in AS patients are derived from echocardiography studies, where systolic pulmonary artery pressure (PAP) is estimated by measurement of peak tricuspid regurgitation velocity. This together with indirect signs of PH gives a reasonable estimate of the probability of significant PH 7 but does not allow assessing the underlying haemodynamic mechanisms of PH in detail …”

Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018

“…A study of 433 patients who underwent pre-interventional invasive hemodynamic assessment showed that pre-capillary PH and CpcPH (defined as DPG ≥ 7 mmHg), but not IpcPH, were associated with a significantly higher 1-year mortality after TAVI [51]. Moreover, persistence of PH post-TAVI is common, and even moderate PH is associated with higher all-cause mortality [52].…”

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

“…[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. Especially, in the field of AVR, the presence of PH is import for risk stratification and provides information for the "heart team" to evaluate whether to undergo surgical (SAVR) or transcatheter AVR (TAVR).…”

“…Especially, in the field of AVR, the presence of PH is import for risk stratification and provides information for the "heart team" to evaluate whether to undergo surgical (SAVR) or transcatheter AVR (TAVR). 6,7,[9][10][11]13,14 Pulmonary hypertension is defined by a mean pulmonary artery pressure (MPAP) ≥25 mm Hg. Although right heart catheterization (RHC) is the "gold standard" for direct measurements of pulmonary artery pressures according to ESC/ERS guidelines, 15 it is an invasive tool and accompanied by possible complications.…”