Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation

Abstract

ObjectiveThe European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown.Methods579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH.ResultsOut of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group.ConclusionsNew ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.

Impact of the 2022 pulmonary hypertension definition on haemodynamic classification and mortality in patients with aortic stenosis undergoing valve replacement

“…We showed that among the PH-defining parameters, PVR was most strongly associated with mortality. This is also in agreement with the recent study by Cardaioli et al , 8 who found that only patients with increased PVR (i.e. CpcPH and pre-capillary PH according to the 2022 definition) but not IpcPH had worse outcomes than those without PH in patients with severe AS undergoing TAVR.…”

“…Still, to the best of our knowledge, it is one of the largest cohorts of AS patients undergoing systematic right heart catheterization prior to AVR and one of the first larger-scale studies evaluating the prognostic impact of the 2022 PH definition in a left heart disease population. Second, our data are in part confirmatory of the results recently reported by Cardaioli et al 8 in a pure TAVR population. However, the advantage of the present analysis is the separation of CpcPH and pre-capillary PH patients and the inclusion of the definition of the unclassified PH group.…”

“…This type of analysis is new because most previous studies on the left heart disease setting have not fully applied the 2022 definition but have concentrated on certain PH groups. 7 , 8 For example, Güder et al 7 concentrated on patients with post-capillary PH only, and Cardaioli et al 8 lumped together pre-capillary PH und CpcPH patients to one single group and have compared them with IpcPH patients and patients without PH. In both studies, there is no information on patients with unclassified PH.…”