Risk of Pulmonary Hypertension in TAVR
Does baseline pulmonary hypertension (PH) identify patients at increased risk of mortality after transcatheter aortic valve replacement (TAVR)?
This study examined 2,180 patients with aortic stenosis at high or prohibitive risk for surgical AVR treated with balloon-expandable TAVR in a randomized trial or registry, and with available invasive hemodynamics. The relationship between baseline PH and outcomes following TAVR was evaluated.
One-year mortality following TAVR was 18.6%, 22.7%, and 25.0% in patients with absent (n = 785), mild (n = 838), and moderate/severe PH (n = 557), respectively (p = 0.01). On multivariable analysis, there was no difference in mortality among males at 1 year between those with mild versus no PH (hazard ratio [HR], 1.2; 95% confidence interval [CI], 0.9-1.6) or moderate/severe versus no PH (HR, 1.2; 95% CI, 0.8-1.6); among females, there was no difference between mild versus no PH (HR, 1.2; 95% CI, 0.8-1.8), although a significant increase in mortality was observed among females with moderate/severe versus no PH (HR, 2.1; 95% CI, 1.4-3.2). Among patients with moderate/severe PH, variables independently associated with mortality included oxygen-dependent lung disease, reduced glomerular filtration rate, decreased aortic valve mean gradient, and an inability to perform a 6-minute hall walk (p < 0.05 for each). Specific hemodynamic variables were not independently associated with mortality in patients with moderate/severe PH.
The authors concluded that females with moderate/severe PH have an increased risk of mortality following TAVR.
Identifying optimal patients for TAVR remains challenging. We need to improve our ability to determine which patients are most and least likely to benefit from this procedure, and this manuscript examines the relationship between the presence of PH on invasive hemodynamics and 1-year mortality following TAVR. This study observes a significant relationship between PH and mortality in females, with no significant difference observed in men. The explanation for this finding remains unclear, and requires validation. The study also identifies specific variables in patients with moderate/severe PH that appear associated with a particularly high risk of mortality. These should be explored in future studies to help us identify which patients are most likely to benefit from TAVR.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Pulmonary Hypertension, Interventions and Structural Heart Disease, Hypertension
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Hypertension, Pulmonary, Heart Valve Diseases, Hemodynamics, Hypertension, Lung Diseases, Risk, Transcatheter Aortic Valve Replacement
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